LIBRARY OF CONGRESS, 

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Chap 1 Copyright No 



UNITED STATES OF AMERICA. 









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Oral Pathology 

and Practice 



A Text-Book for the Use of _ Students in Dental 

Colleges and a Hand-Book for 

Dental Practitioners. 



/ 

By W. C. BARRETT, M.D., D.D.S., M.*D.S. 

Professor of Oral Pathology in the University of Buffalo Medical Department 

Professor of Dental Anatomy and Pathology in the Chicago College of 

Dental Surgery; Professor of the Principles and Practice of 

I (entistry and Oral Pathology in the University of 

Buffalo Dental Department; Oral Surgeon 

to the Buffalo General Hospital, 

etc. etc. 



PHILADELPHIA: 
THE S. S. WHITE DENTAL MFG. CO 



** 



-V 



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X* 



1 11/40 



Copyright, 1898, by W. C. Barrett. 




rwoc OEIVED. 



9f 



TO 
My beloved Associates in College Work, 

AND TO 

My Boys, 

THE MEMBERS OF THE VARIOUS CLASSES WHO HAVE 

BEEN UNDER MY INSTRUCTION, AND WHOM 

I HAVE SOUGHT TO SERVE, 

THIS WORK 
IS AFFECTIONATELY INSCRIBED. 



PREFACE. 



This book is not a treatise, and surgical or operative pro- 
cedures form no part of its scheme. In writing it the first object 
has been to condense, not to amplify, that it may be published at as 
low a price as possible. With this end in view, cuts have been 
excluded, desirable as they might in some instances be. The 
work has thus been kept within the limits of a manual. 

It has been the aim of the author to consider as succinctly as 
is consistent with clearness the functional derangements of all the 
oral tissues that properly fall within the compass of a broad dental 
practice. In addition to this there are certain constitutional dis- 
orders, the effects of which may be observed in and about the oral 
cavity, which have not as yet been incorporated into our specialty, 
and perhaps never will be, yet of which it is essential that the 
dentist should have sufficient knowledge to enable him to make a 
clear diagnosis, even if he should not purpose active remedial 
measures. Such disorders as facial paralysis, syphilis, and tumors 
have therefore been given a general consideration, but practitioners 
who wish to make a more exhaustive study of those subjects are 
referred to special works upon them. 

It should not be expected that a writer would blindly and 
unreservedly follow even accepted practice when in his opinion it 
is founded in error: such a course would make of him a mere echo, 
and would inhibit originality and progress. If, therefore, the 
author has advanced his own ideas upon subjects concerning which 
there is a difference of opinion, he believes them entitled to candid 
consideration in the light in which they are presented. If not 
found in harmony with clinical experience and observation, they 
disprove themselves. 

It is only within a few years that Pathology as a separate study 
has been made a distinct pari of the curriculum o\ our colleges. 
The treatment of a few of the more pronounced pathological condi- 
tions has always been included in the course of lectures upon 

v 



VI PREFACE. 

Operative Dentistry, or in that of Materia Medica and Therapeu- 
tics, but the subject has been made rather incidental than founda- 
tional. With the growth of dental practice and the expansion of 
the course of instruction in our colleges, a more extended con- 
sideration of the treatment of complications naturally attendant 
upon dental degenerations becomes a necessity in our best schools. 
Dentists are reasonably plentiful, and the multiplication of institu- 
tions devoted to their training is believed to promise an even 
more abundant supply. The complaint that the profession is 
getting uncomfortably crowded arises from the old graduates, as 
well as from those who have been deprived of the advantages of 
scholastic training. 

The remedy for these conditions can only be found in the 
deepening of the stream — in the enlarging of the field of practice 
by incorporating with the methods of the past (the mechanical 
and operative procedures which have already been carried to such 
a high state of perfection) the treatment of the diseases that prop- 
erly fall within the province of the oral physician, and the making 
of Oral Practice a true specialty of medicine. 

For some years the author has annually delivered before his 
classes in dental colleges from fifty to sixty lectures upon patho- 
logical and morbid functional and structural conditions in the oral 
cavity and the tissues immediately connected with it, in which there 
has been attempted nothing of instruction in constructive, opera- 
tive, or manipulative dental work. This has tended to open for 
students a field insufficiently cultivated by dentists. It has en- 
larged their opportunities, added to their emoluments, and given to 
them a better professional status. 

But in this line of teaching he has been seriously handicapped 
by the absence of proper text-books. Excellent treatises were in 
existence, but none of them was exclusively devoted to the every- 
day work of either student or practitioner. They included other 
branches of dental science, and while, as works of reference and as 
text-books for advanced members of the profession who desired 
to make special studies in scientific fields, they were much better 
adapted than a work of this kind can possibly be, yet as hand- 
books for students in colleges and as everyday manuals for those 
who sought help in the hourly recurring complications of office 
life they were too voluminous. 

In the time of Hippocrates it was possible to comprise in one 



PREFACE. Vll 

volume all that was known of medicine. Many of our older 
practitioners can call to mind the days when the whole art of den- 
tistry was imparted by a preceptor in a few easy lessons. One 
man might then be universally recognized as the highest authority 
in the whole field. Xow, a complete knowledge of any one of the 
distinct branches of medicine demands a post-graduate course after 
four years of general study, while three years in a dental college 
are scarce sufficient to enable the student to master the basal 
principles of our greatly extended oral practice. Not alone medi- 
cine, but dentistry is divided into specialties, and already there are 
among us those who give their exclusive attention to Operative or 
to Prosthetic work, to Oral Surgery, to Odontothorsis or to 
Odontotherapy. The tendency seems to be toward the teaching 
of each branch in separate classes, with distinct text-books for the 
several departments. The present work grew out of that seeming 
drift, and the germ of its existence lay in the notes of lectures upon 
the subjects considered. 

The book could easily have been expanded into greater dimen- 
sion >, but that would have limited its usefulness among those for 
whom it was specially prepared. Extended abstracts of the writ- 
ings of others might have been included with profit, but that would 
have swollen the volume beyond the limits set for it, and have 
added to its cost. Besides, a book should have a distinctive indi- 
viduality, a personality as pronounced as that of the successful 
teacher, and without this it is usually as insipid as is the man who 
possesses no distinguishing peculiarities. So it is perhaps better 
that it should be marred by some of the many faults of its author 
rather than be without any special traits at all. 

W. C. B. 
208 Franklin St., Buffalo, N. Y., 

Jinir, 1898. 



CONTENTS. 



CHAPTER I. page 

General Considerations i 

CHAPTER II. 
Bacteriology: Classification 3 

CHAPTER III. 
Fermentation 7 

CHAPTER IV. 
Bacteriological Pathology 11 

CHAPTER V. 
Septic and Aseptic Conditions 14 

CHAPTER VI. 
Inflammation: Its General Characteristics 19 

CHAPTER VII. 
Changes Attending the Inflammatory Condition 23 

CHAPTER VIII. 
Further Degenerative Changes 27 

CHAPTER IX. 
'I in. Products of Inflammation 30 

CHAPTER X. 

< rENERAL TREATMENT OF INFLAMMATION 35 

CHAPTER XI. 
■ ii : Gums 39 

CHAPTER XII. 
Stomatitis 42 

CHAPTER Kill. 

Tre \t\i i.\t OF Stomatitis 15 

''II M'TKK XIV. 
I'm ■ RYNGITIS AND TONSILLITIS 49 

ix 



X CONTENTS. 

CHAPTER XV. page 

Diseases of the Tongue 52 

CHAPTER XVI. 
Diseases of Dentition: General Considerations 54 

CHAPTER XVII. 
The So-called Diseases of Dentition 58 

CHAPTER XVIII. 
Treatment of the So-called Diseases of Dentition 64 

CHAPTER XIX. 
Real Diseases of Dentition 67 

CHAPTER XX. 
Dental Caries 70 

CHAPTER XXI. 
Dental Caries (Continued) 73 

CHAPTER XXII. 
The Medicinal Treatment of Dental Caries ~j 

CHAPTER XXIII. 
Pulpitis— Inflammation of the Dental Pulp 80 

CHAPTER XXIV. 
Treatment of Inflammatory Conditions of the Dental Pulp... . 84 

CHAPTER XXV. 
Pericementitis— Inflammation of the Peridental Membrane.... 88 

CHAPTER XXVI. 
Alveolar Abscess 92 

CHAPTER XXVII. 
Symptomatology and Treatment of Alveolar Abscess 97 

CHAPTER XXVIII. 
Deposits upon the Teeth 103 

CHAPTER XXIX. 
Pyorrhea Alveolaris 107 

CHAPTER XXX. 
Pyorrhea Alveolaris (Continued) 109 

CHAPTER XXXI. 
Facial Neuralgias 115 

CHAPTER XXX TI. 
Facial Paralysis 119 



CONTEXTS. XI 

CHAPTER XXXIII. 
Sympathetic Disturbances 122 

CHAPTER XXXIV. 
Diseases of the Maxillary Sinus 125 

CHAPTER XXXV. 
Treatment of Diseases of the Maxillary Sinus 130 

CHAPTER XXXVI. 
Diseases of the Frontal Sinus 135 

CHAPTER XXXVII. 
Cysts and Their Treatment 137 

CHAPTER XXXVIII. 
Tumors and Neoplasms 141 

CHAPTER XXXIX. 
Tumors and Neoplasms (Continued) 144 

CHAPTER XL. 
Osteitis < 148 

CHAPTER XLI. 
Caries of Bone 151 

CHAPTER XLII. 
Necrosis 155 

CHAPTER XLIII. 
Treatment of Necrosis 158 

CHAPTER XLIV. 
Hypersensitive Dentin 161 

CHAPTER XLV. 
Treatment of Hypersensitive Dentin 165 

CHAPTER XLVI. 
Sei ondary Dentin, Pulp Nodules, and Calcifications 171 

CHAPTER XLVII. 
Hyi ercementosis 174 

Ml M'TKU XLV II I 
Dist olored Teeth 175 

CHAPTER XL IX. 
Abrasions; Pitted and Furrowed Teeth 177 

CH M'T! 1 1 
vntation; Transplantation; I mplantatton iSr 



xii CONTENTS. 

CHAPTER LI. PAGE 

Syphilis: The Primary Stack 186 

Ml M'TI-'.R LI I. 
Syphilis (Continued) : Th ry Stack 189 

CHAPTER LIU. 
Tertiary and Hereditary Syphilis 19-2 

CHAPTER LIV. 
Syphilis of the Mouth and Tongue 194 

PTER LV. 
Physical Diai josis: IThe Pulse 196 

CHAPTER LVI. 
i. Diagnosis (Continued): The Respiration 201 

CHAPTER LVII. 
\l Tissues ix Diagnosis 205 

CHAPTER LVI II. 
. ' 1 - and Injuries 208 

CHAPTER LIX. 
Treatment of Wounds 211 

CHAPTER LX. 
Excessive Bleeding 216 

CHAPTER LXI. 
Fractures and Their Treatment 2t8 

CHAPTER LXII. 

I Casks ok Fracture 222 

CHAPTER LXIII. 
Dislocations and Sprains 22g 

CHAPTER LXIV. 
Shock — Collapsk 228 

CHAPTER LXV. 

I I nt ok Shock 232 



ORAL PATHOLOGY AND PRACTICE. 



CHAPTER I. 
GENERAL CONSIDERATIONS. 

The study of disturbed, as well as of normal systemic condi- 
tions, necessarily commences with the consideration of Function. 
Health and sickness (ease and dis-ea.se) are dependent upon the ac- 
tivities of the organs of the body. In the former condition all are 
harmoniously working together, each accomplishing its proper 
task in the best manner and at the right moment. In the latter 
there is a disturbance of the harmonious bodily relations through 
the inaction or the mal-action of some organ or set of organs, in- 
duced by malnutrition, by unsanitary conditions, or by external in- 
terference. 

Function is the action of an organ, or of a complete set of 
organs. The function of digestion implies the proper action of all 
the organs of the digestive tract, and the perfect accomplishment of 
this function requires that each of them shall be in that state of 
health which is secured only by the normal action of all com- 
bined. 

The' function of insalivation demands that all of the salivary 
glands shall be in a normal condition, secreting healthy saliva, 
and that the saliva shall be properly mixed with ingested food. 

Physiology is the science of normal function. Its proper 
study demands a knowledge of the structure of the organs con- 
cerned. It is not confined to man, or even to animal life. Wher- 
ever there is vitality, growth, organs (that is, in all organic matter) 
there arc certain laws that govern the functional activity of the 
organism; and the study of these laws is called Physiology. 

Physiology is divided into animal and vegetable phys- 
iology. It may again be subdivided, until the functional activity 
of each of the various orders of animal and vegetable life is. 
specially considered. 



2 ORAL PATHOLOGY AND PRACTICE. 

Pathology is the study of perverted, abnormal, or diseased 
function. Its comprehension must be based upon a knowledge 
of healthy action. The study of pathology may be divided in the 
same manner as is physiology. Wherever there is normal func- 
tion there may be diseased or perverted action of the tissues or 
organs, if their activity is in any way disturbed. So we may have 
animal or vegetable pathological action, and we may study this 
aberration in any class of animals or vegetables, even in any 
separate organ or tissue; thus we speak of human or animal 
pathology, and of pathological conditions of the digestiv.e appa- 
ratus, the kidneys, the pulmonary tissues, the oral cavity, the nails, 
the teeth, the hair, etc. This unrestricted nature of the study 
must always be kept in mind, and the fact that in the consideration 
of the diseases that are incident to man we are but making an 
examination of a small portion of the great field of perverted 
activity, should never be lost to sight. 

Oral pathology is but a branch of disturbed human 
function. While we may make special inquiries into its charac- 
ter, it can never be wholly segregated from its connections, but 
must always be considered in its relations to impaired conditions 
of other organs, because its initial lesion, or point of origin, may 
be in them, and a cure may only be brought about through a 
return of those connected organs to a true state of physiological 
action. There is no proper study of the oral tissues or organs, 
aside from their functional association with other tissues and 
organs. 

A physiological state may be changed to a pathological condi- 
tion by any derangement of function. The modifying influences 
may be classed as follows : 

i. Perverted nutrition (or malnutrition). 

2. Unsanitary surroundings or environments. 

j. External interference. 

Their importance as disturbing factors is in the order given. 

Malnutrition means the improper nourishment of the tissues 
or organs. It may primarily depend upon improper food, a lack 
of food, or upon imperfect action of the organs of digestion and 
assimilation. A degenerate condition of these organs is usually 
brought about either by impaired nutrition or unhealthy environ- 
ment, and may therefore be considered as a secondary cause. 

Unsanitary or unhygienic conditions are those that interfere 



bacteriology: classification. 3 

with proper functional activity, by means of some disturbing 
element or influence, such as 

a. Contamination of the air that is breathed, or the food or drink 
that is taken. 

b. Subjection of the organs and tissues to improper extremes of 
temperature. 

c. Promotion of the proliferation and growth of parasitic or 
disease-producing organisms. 

External interference has reference to factors not primarily 
connected with functional disturbances. It includes wounds and 
injuries, the influence of excessive heat and cold, the active agency 
of corrosive poisons, and such-like extraneous causes. 



CHAPTER II. 

BACTERIOLOGY: CLASSIFICATION. 

Modern pathological science is largely founded upon a knowl- 
edge and study of the bacteria — a subdivision of the fungi. The 

influence of these organisms upon the body is so overwhelming 
that it is impossible to comprehend pathology without a knowledge 
of their character and action. So many of the diseases most de- 
structive to man are caused by them, that modern medical science 
is largely based upon their study. Notwithstanding the fact that 
they can only be seen by the aid of the higher powers of the micro- 
scope, and that even then some of them are absolutely indefinable 
to vision, they work the most important changes in matter. 

The office of the fungi seems chiefly that of destruction. By 
their growth they decompose organic matter in which function 
has ceased, and return its elements to nature, to be again built 
up into other structures by varying functional activities. 

Different names have been given to these organisms by 
different pathologists, though all have the same general signifi- 
cation. 

a. Micro-organism means a small body. 

b. Microbe signifies a small life. 

c. Bacterium (plural Bacteria), a small staff. 

d. Bacillus I plural Bacilli), a small rod. 

It w ill be seen thai the first two and the last two are practically 



4 ORAL PATHOLOGY AND PRACTICE. 

synonymous. Micro-organism is a term as comprehensive as any, 
although it has no strictly scientific significance. All of these 
bodies that come within the field of the pathologist are microscopic, 
hence the term micro-organism is more appropriate than to call 
them fungi, the latter term including many organisms that are 
merely parasitic upon other vegetable growths, and many of the 
fungi not being microscopic and having no pathological signifi- 
cance. 

They have been differently classified by various observers. 
These have based their arrangement upon special characteristics. 
That of Miller, in his "Micro-organisms of the Human Mouth," is 
perhaps best adapted to the needs of students of oral pathology, 
and it is therefore accepted as the standard for this work. The 
following table will give a clear idea of it: 
Matter 



Organic 



Inorganic 



Animal 



Vegetable 



Cryptogams Phanerogams 

(Flowerless plants, propagating (Flowering plants, propagating 
by spores) by seeds) 



Thallogens, 


Leafy Cryptogams, 




or Thallophytes 


(Ferns, Mosses, etc.) 




Lichens 


Fungi 


Alg:« 


Screw forms 


Rod forms 


Round forms 


Vibriones 


Bacilli 


Micrococci 


(undulating) 


(straight rods) 


(small cocci) 


Spirilla 


Clostridium 


Macrococci 


(rigid) 


(spindles) 


(large cocci) 


Spirocheta 


Leptothrix 


Diplococci 


(flexible) 


(threads) 


(double cocci) 
Streptococci 
(chain cocci) 
Staphylococci 
(group cocci) 



Organic matter is that which is the product of function, or 
growth. Everything that has organs, or in which function exists 
or has once existed, is organic. 

The organic world is divided into two great kingdoms, the 
Animal and the Vegetable. Each individual member of these 



bacteriology: classification. 5 

great divisions has its organs and its tissues; function exists in 
each as long as there is vitality, or life. Death is merely the cessa- 
tion of function. 

The food of these two kingdoms materially differs. The 
animal can assimilate nothing except organic matter. Thus the 
Graminivora live upon vegetables alone, or matter that has been 
but once organized, and require a complicated digestive system 
to extract the comparatively small amount of pabulum for their 
tissues which it contains. The Carnivora feed upon the animal 
kingdom, or matter that has been twice organized; first into the 
vegetable and then into the animal. Their digestive apparatus 
is comparatively simple, because of the concentrated nature of 
their food. The Omnivora, to which division man belongs, can 
subsist upon either, and their digestive organs, while more com- 
plex than those of the Carnivora, are considerably modified from 
those of the Graminivora. 

Only organisms that belong to the vegetable kingdom 
have the power of living upon inorganic, or unorganized 
matter. Certain of the vegetable fungi are unable even to do 
this, but must have the food organized before they can assimilate 
it, as must all members of the animal kingdom. 

Inorganic matter is that which exists as it was first created. 
This earth, when it left the hands of the great Creator, must have 
consisted of inorganic matter. When, in due process of time, 
the first organic cell was created, and endowed with the power to 
adapt itself to changing environments and to perpetuate its species 
— in other words, was invested with function — its food, or pabulum, 
must have been derived from the inorganic creation. But only the 
vegetable kingdom has the power to assimilate or organize this 
matter, or to subsist and grow upon that which is as it was 
primarily created. Hence the vegetable was first in the order of 
organic creation, and all organic matter, which is the product 
of function and was primarily derived from the inorganic, must 
have originally been the result of vegetable action. 

No animal can utilize for trophic, or digestive, purposes any 
inorganic matter whatever. This is a law of the creation. All 
the mineral elements that enter into the composition of onr teeth. 
bones, etc., must be obtained from organic sources. That is, the 
calcium, phosphorus, iron, etc./ of our tissues must have been 
derived from matter that had first been built into other life. Inor- 



6 ORAL PATHOLOGY AND PRACTICE. 

ganic matter may be utilized in the system as medicine, but it will 
be extruded in the same form in which it entered; it cannot be 
built up into the tissues. It necessarily follows, then, that in the 
order of the developmental history of the world, the vegetable 
must first have had a being, to provide food for the animal. 

The vegetable kingdom is divided into the classes Phanerogam 
and Cryptogam. 

The Phanerogams include all those plants which have 
blossoms and which are propagated by seeds. The roots 
of some phanerogams, as the potato, enlarge into tubers, from 
which new plants may be grown, but their real generation is from 
seeds. Most of the plants with which we are acquainted belong to 
this class. It is the seeds and the tubers of the phanerogams that 
form the principal vegetable food of man. 

The Cryptogams never blossom, and their propagation 
is by spores, or minute embryos of the plant itself. As the 
potato may be propagated from divisions of the root or tuber, so 
do many of the cryptogams grow from divisions of the organisms 
themselves, but primarily their origin is from spore-cases. 

The Leafy Cryptogams are not microscopic in their 
character, and they have distinct branches and stems. 
But, like all of their class, they grow from spores. The leafy- 
cryptogams include the ferns, the mosses, and some of the lichens. 

The Thallogens, or Thallophytes, belong to that divi- 
sion of the cryptogams that are unicellular in their struc- 
ture. They are without leaves, stems, or branches. They are 
divided into Fungi, Algae, and Lichens. 

Fungi are without chlorophyll (the green coloring 
matter of plants), and live only upon organic matter. They 
are found as the parasites of both the animal and vegetable king- 
doms. 

Algae contain chlorophyll, but live upon inorganic 
matter. They are usually found growing in the water. 

Lichens partake of the character of both the fungi and 
the algae. They may or may not contain chlorophyll, and they 
may live upon either organic or inorganic matter, according to 
their species. 

It will be observed that only the fungi can be of interest to 
the pathologist, for the algae do not grow upon organic matter, 
and hence will not be found parasitic in man, whose structure is 
organic. 



FERMENTATION. 7 

The Fungi are divided according to their shape, into 
round, rod, and screw forms. The round, or coccus forms, are 
subdivided into the macrococci, or large cocci, the micrococci, or 
small cocci, the diplococci, or double cocci, the streptococci, or 
chain cocci, and the staphylococci, or those which grow in clus- 
ters, like a bunch of grapes. 

The rod forms are divided into the bacilli, or straight rods; 
the Clostridium, or spindle-shaped, and the leptothrix, or thread- 
like forms. 

The screw forms are divided into the vibriones, or undulating 
screws; the spirilla, or rigid, and the spirocheta, or flexible screws. 
This subdivision as to form is for convenience, and has no special 
pathological significance. 

Classed according to their action the fungi are divided into 
other classes, such as Zymogenic (fermentative), Pathogenic 
(disease-producing), Chromogenic (coloring), Aerogenic (gas- 
forming), Saprogenic (putrefactive), Pyogenic (pus-producing), 
Saprophytic (parasitic), etc. 



CHAPTER III. 
FERMENTATION. 



Fermentation may be defined as the change brought about in 
an organic medium by the presence of a ferment. It is only within 
a recent period that its true nature has been comprehended. It 
was formerly ascribed to what was called catalytic action. It is 
now known to be induced by a special organism or substance, and 
its phenomena are those produced by the decomposition of the 
medium in which the ferment is growing, or exhibiting its energy. 

There are organic and inorganic ferments. 

The organic ferments are certain of the micro-organisms 
whose growth or proliferation is by the assimilation of the 
elements of the fermentable substance. This they have the 
power to decompose, as a cabbage disintegrates and resolves into 
its elements the soil in which it grows. 

The inorganic ferments are those of digestion. The 
gastric and intestinal juices, the saliva, etc., contain ferments that 
decompose and change the fermentable foods, and reduce them 



8 ORAL PATHOLOGY AND PRACTICE. 

to a condition in which they may be assimilated, or built into 
tissue. 

It is only fermentable organic matter that can be thus 
digested and assimilated. Inorganic matter is incapable of 
fermentation, and hence cannot serve as food for any of the 
tissues of the animal. 

The classification of the fungi shows that they are as 
distinctly vegetable as is a potato or a geranium. The fact 
that they belong to a different order, and are cryptogams instead 
of phanerogams, does not change this. They require for their 
development the same essential conditions and elements. They 
must have the proper soil, or menstruum, in which to proliferate, 
or grow. They require a proper amount of moisture, as does 
corn or wheat. They demand a fitting temperature, and are 
destroyed, or cease to vegetate, when that is either too high or 
too low, as do grass, trees, and shrubs. 

The media, or soils or materials in which the different species 
of micro-organisms grow are as various as are the fungi themselves. 
Some require a sugar solution, made from the fermentable sugars 
formed by the change of starch into the so-called grape sugar. 
Some demand an infusion prepared by steeping vegetables belong- 
ing to the phanerogams. Some grow only in gelatins. Others 
exist only in the tissues, or extracts of the tissues, of animals. 

The temperature best adapted to their growth varies 
with the organism. With those that live in the tissues, that 
which is normal to the body is also normal to them. 

The growth of the organisms, although primarily from 
spores, goes on in various ways. 

Segmentation is the spontaneous division of a micro-organism 
into segments, or sections. Each is complete in itself, and each 
in turn subdivides into others. 

Gemmation is the process of proliferation by 'budding. This is 
the growth of one organism out of another, and its final separa- 
tion from the parent. 

Fission is the division of an organism into two or more parts 
by a constriction of its body. This contraction gradually deepens 
until the separation is complete. 

Spore formation occurs when in certain stages of its life-history 
an organism undergoes special changes. In these the interior breaks 
up into exceedingly minute embryos, which are liberated and 



FERMENTATION. 9 

disseminated by the bursting of the external envelope. Many 
of the organisms which at certain stages of their existence pro- 
liferate by means of segmentation or gemmation, after a definite 
time break up into spores. Something analogous to this exists 
among phanerogams, the potato, for instance, being propagated 
by subdivision of its tubers, but in due process of time blossoming 
and forming seed-cases. 

The growth of micro-organisms proceeds by the decomposition 
of the medium in which they exist. They assimilate such of its 
elements as enter into their own composition, and in so doing 
form various waste products, and give rise to new combinations 
of such of the elements of the medium as are rejected. 

Under favorable circumstances, micro-organisms multiply with 
almost inconceivable rapidity. Cohn estimates the life-history of 
a single bacterium at an hour, at the end of which time it will 
divide into two or more. He computes that from a single indi- 
vidual, if all the circumstances were favorable, within five days the 
product might fill all the seas of the globe. 

The proliferation of the Torula, or Yeast-plant, may be taken 
as a type of the whole process. This fungus consists of single cells, 
produced by division of the parent cell. It grows in sugar solu- 
tions with the greatest rapidity, but a short time being required for 
the permeation of a large mass by the product of a single cell. The 
process of making bread illustrates this. The housewife mixes 
flour, which consists of starch, that is easily converted into a fer- 
mentable sugar, with a sufficiency of water; she then places the 
product in a warm place, after having introduced a few cells of the 
yeast-plant. Here are all the elements needed for development — a 
suitable medium, sufficient moisture, and the proper temperature. 

The yeast-plant commences its growth and permeates all 
parts of the mixture. It decomposes the sugar, separating the 
oxygen, carbon, and hydrogen. It builds into itself that which 
is necessary and rejects the other atoms, which immediately enter 
into new combinations, forming as by-products, alcohol and carbon 
dioxid. Wherever a cell of the yeast-plant is formed, there is a bit 
of alcohol and a minute globule of carbon dioxid gas. The latter 
distends the dough, or causes it to "rise." When this is completed 
it is placed in the heated oven, with the result that the yeast-plant 
is killed, and the dough is fixed, or cooked, and becomes bread. 
Beer-making is an analogous fermentation. 



10 ORAL PATHOLOGY AND PRACTICE. 

The alcoholic -fermentation is that which results in the formation 
of alcohol as one of the by-products. The fermentation of grape 
juice, and the formation of alcohol from the starch of various 
grains, belong to this class. The growth of the ferment produces 
alcohol, which is held in solution in the water, and is then distilled 
off by its evaporation at a comparatively low temperature. 

The acetous, or acid, fermentation is the growth of yet another 
organic ferment, that leaves as its by-product an acid. Of this char- 
acter is the organism Mycoderma aceti, or the so-called "mother" 
of vinegar. It decomposes a sugar solution, and produces acetic 
4 acid as a by-product. Others of the fungi produce gelatin, and 
yet others various gases. 

The putrefactive organisms decompose nitrogenous matter by 
their growth, with the evolution of offensive gases as their by- 
products. All the fungi grow at the expense of the medium in 
which they exist, and through its decomposition, or change. 
Their by-products vary with the organisms themselves, and, as 
in the case of the ptomains and toxins, are sometimes of such a 
poisonous nature as to induce diseased or pathological conditions. 

Some of the fungi grow only in the presence of air or 
oxygen, and hence are called "aerobic," while others 
flourish in tissues or cavities to which air has no access, 
and are called "anaerobic." 

The bacteria generally are self-limiting. Their own by- 
products are fatal to them, and when the medium in which they 
are growing becomes sufficiently contaminated the organisms 
will perish. Thus, when an acid-producing organism has made 
its menstruum sufficiently acid, it will die unless the acid is 
neutralized by an alkali, in which case it goes on proliferating, 
provided the pabulum is not exhausted. All the fermentable 
material in a solution may be used up and decomposed, so that 
there will no longer be food for the organism, in which case it 
will die out. 

One organism may destroy and supersede another by 
its superior activity and power of decomposition, or through 
its production of a chemical compound that is fatal to the 
first. The brewer must use the most scrupulous care to prevent 
the intrusion of a strange organism into his infusion, or the result 
may be an acid instead of an alcohol, with the consequent souring 
of his beer. 



BACTERIOLOGICAL PATHOLOGY. II 

CHAPTER IV. 
BACTERIOLOGICAL PATHOLOGY. 

From the standpoint of the pathologist, the micro-organisms 
may be divided into several classes, according to their action npon 
the animal economy. 

PatJwgenic microbes are those whose proliferation or whose by- 
products cause specific pathological changes; they are disease-pro- 
ducing. 

Saprogenic organisms are those which cause putrefaction; those 
which give rise to the formation of pus, or induce suppuration, being 
termed pyogenic. 

Saprophytic bacteria are those which are merely parasitic; they 
live at the expense of that upon which they groiv. They are found in 
connection with putrefactive changes. 

For the study of any of these micro-organisms it is necessary 
to make pure cultures, obtained by implanting them, as they are 
mixed with others, in the best culture media, and separating out 
and replanting until everything has been eliminated save that 
which it is desired shall be investigated. They cannot be iden- 
tified by a microscopic inspection of the organisms themselves, — 
they are too minute for this purpose. But by observation of the 
phenomena of their growth, and by tests of their products, as well 
as by staining them with certain anilin dyes which do not affect 
their surroundings, they may readily be differentiated, or distin- 
guished from other organisms. 

To produce a pure culture of any organism, an incubator, 
or growing-chamber, is required, in which the exact amount of 
moisture and the proper temperature may be maintained prac- 
tically unchanged for a definite period. 

Micro-organisms penetrate everywhere that air can go. 
So innumerable are the different species, and so minute their size, 
the spores of many of them being invisible even beneath the 
highest powers of the microscope, that everything conceivable 
becomes infected with the seeds of disease and decay. A single 
species has in the past caused greater alarm and devastation than 
all the armies of the most pitiless conqueror who ever ravaged the 
earth. The bacillus that produces cholera lias decimated nations. 
The various plague bacteria have invaded great cities and de- 



12 ORAL PATHOLOGY AND PRACTICE. 

stroyed every second person. They have defeated and dispersed 
invading armies, and have stayed the march of destroying hosts. 
The bubonic plague, which is the result of the growth of a patho- 
genic organism, has, in the past, swept away one-third of the 
population of Europe in a single invasion. 

A few of the most fatal of the maladies which are the direct 
result of the growth of some special organism, and which are 
therefore contagious in their character — the so-called zymotic 
diseases, of either epidemic or endemic origin — are the following: 
Cholera, Diphtheria, Relapsing Fevers, Leprosy, Typhoid Fever, 
Syphilis, Smallpox, Septicemia, Osteomyelitis, Tuberculosis, 
Lupus, Tetanus, Glanders, Actinomycosis, Malignant Pustule, 
Gonorrhea, Leucorrhea, Scarlet Fever, Mumps, Meningitis, Ery- 
sipelas, Carbuncle, Pneumonia, Rabies, Anthrax. 

Late investigations have shown that the one malady that 
in this country is responsible for more deaths than any other, tuber- 
culosis or consumption, is as communicable as smallpox, and can 
only be acquired through infection. Its period of incubation, or 
development, is longer than that of most infectious diseases, but it 
can be as certainly stamped out by disinfection and the use of anti- 
septics as can cholera, that former scourge, which in the light of 
our modern knowledge of bacteriology is now so readily con- 
trolled. 

Were there no means of resisting the invasion and growth of 
the special organisms which induce these diseases, and of impeding 
their multiplication, they would inevitably depopulate the earth. 
It has already been asserted that they are self-limiting in their 
proliferation, through their inability to exist in the presence of 
their own waste products. They may also exhaust the soil or 
medium in which they grow, and thus circumscribe their own 
multiplication. 

The most material factor in the prevention of the in- 
crease of the zymotic diseases is the resistive power of 
healthy animal function. Lender ordinary circumstances, the 
human body successfully reacts against infection, and prevents 
undue proliferation of pathogenic organisms. If, however, the 
bodily tone is depressed through malnutrition, by unsanitary con- 
ditions, by fatigue or exhaustion, or because of functional disturb- 
ances, the resistive force of the body is so much weakened, and 
the conditions favorable to the growth of the disease fungi so 



BACTERIOLOGICAL PATHOLOGY. 1 3 

augmented, that they multiply to an extent sufficient to bring 
about that pathological condition which accompanies their inva- 
sion. 

Conclusive experiments upon animals have demonstrated this. 
Rabbits are immune to tubercular infection under ordinary condi- 
tions. Twelve of these animals were selected; six of them were 
kept for some time in a dank and noisome cellar, and insufficiently 
fed upon unwholesome food. The other six were kept in complete 
sanitary condition, in light and airy rooms, and were fed with 
the best food. At the end of a definite period each was inoculated 
with Bacillus tuberculosis. All of the first six took the infection 
and died of it; the six whose bodily tone had been preserved by 
pure air and good food retained their immunity, and successfully 
resisted infection. 

Twelve rats were selected, and six of them placed in a 
revolving wheel that forced them to run at a rapid gait for a 
considerable time. The other six were allowed to remain in a 
quiet place, where they would not be annoyed or irritated. When 
the first six had been forced to run until they were exhausted, all 
the twelve were inoculated with an organism from which under 
ordinary circumstances rats have exemption from infection. 
Those whose resisting powers had been reduced by extreme 
fatigue and exhaustion took the contagion and died, while the 
others were unaffected. 

The resistive power of the human body, according to Metch- 
nikoff, is inherent in the ameboid white blood corpuscles, which 
in a state of health envelop and digest the bacteria. When these 
are not fully formed in the system, when they are diminished in 
number or reduced in functional activity, the infective organisms 
may obtain such preponderance as to overcome all resistance, and 
run their course until they produce death, or become self-limiting 
(Jirough the formation of their own products and the exhaustion of 
the media in which they grow. 

The bacteria are greatly multiplied in the presence of any 
putrefactive or decomposing material. Hence all decaying matter 
should be destroyed as far as possible, by some quicker and more 
hygienic process than its decomposition by the fungi. Sanitary 
conditions imply the removal of all infective matter, and modern 
hygiene is mainly the study of how best to accomplish this. Such 
progress has been made within the past generation, that the 



14 ORAL PATHOLOGY AND PRACTICE. 

average period of human life has been lengthened several years, 
almost entirely through the ability of sanitarians to control the 
multiplication of disease spores. 



CHAPTER V. 
SEPTIC AND ASEPTIC CONDITIONS. 

The state of infection by disease-producing, or putrefactive, 
organisms is called a septic condition, and whatever tends to 
combat this is said to be antiseptic in its character. A state of 
freedom from all degenerative organisms is an aseptic or sterile 
condition, and it may be brought about by various agencies, either 
of a physical or medicinal nature. As moisture is one of the 
elements necessary to the growth of the fungi, it may be readily 
comprehended that its entire emoval will stop all development. 
The proper degree of temperature is essential to growth, and the 
raising or lowering of this beyond a certain point will limit or 
prohibit it, a definite amount of heat being sufficient to destroy 
all organisms, and render sterile any substance whatever. 

There are also certain drugs that have the ability to 
destroy or prevent the growth of septic organisms. 

Those that arc fatal to the bacteria and their spores are called 
Germicides. 

Those that limit and prevent their growth are classed as Anti- 
septics. 

Tliose that decompose or remove the by-products of infection 
arc called Disinfectants. 

Those that either mask or remove the offensive smells of putre- 
faction are denominated Deodorants. 

The most effective of all the agents used for sterilization is 
heat. The temperature of boiling water (212 F., ioo° C.) is fatal 
to many of the septic organisms. But as the spores of some of 
them may successfully withstand this, it cannot in all cases be de- 
pended upon. Continuous boiling for some time will be sufficient 
to destroy most of the organisms contained in water. Yet, if it is 
to be positively sterilized, it must be distilled. If an instrument is 
passed through the flame of burning gas, or of an alcohol lamp, it 



SEPTIC AND ASEPTIC CONDITIONS. 1 5 

will be made positively sterile, but this is in some cases impracti- 
cable, because it will destroy the usefulness of steel tools by draw- 
ing the temper. The tissues of the body, and of most organic mat- 
ter, cannot be raised to a temperature sufficient to insure an aseptic 
condition, and hence we are compelled to depend upon germicides, 
antiseptics, and disinfectants in the treatment of septic conditions. 

Most germicides are to a greater or less extent antiseptic in 
their nature. That is, agents that have the power to destroy 
germs will also prevent their growth. Many of the antiseptics 
are" at the same time germicides and disinfectants, and vice versa. 
In the selection of drugs for medicinal purposes it is necessary 
to consider something more than their germicidal or antiseptic 
qualities. One that is a virulent poison cannot with safety be 
administered internally, nor can one that is a cauterant be used 
on delicate tissues. It is therefore necessary to comprehend the 
therapeutics of antisepsis, and to select the remedy to be used in 
full view of these facts. 

Pure germicides are not always demanded in actual practice. 
If a disinfectant is first employed to remove the products of sepsis, 
and to cleanse the infected tissues, antiseptics that will prevent 
further microbic action will ordinarily secure the desired end. 

The necessities and conditions of oral practice are 
such as to exclude many disinfectants, unless they are 
securely sealed up within the cavity of a tooth. If they 
are of a caustic nature, they will induce complicating lesions. 
If they are specially toxic^ or poisonous, they may bring about 
serious derangements. Therefore, in their selection, the judicious 
practitioner will exercise great care, and choose those which, with 
the highest degree of effectiveness in their special action, are at 
the same time innocuous to other tissues. In this respect car- 
bolic, or phenic, acid, a drug that has been in most common use 
in oral practice, is exceedingly objectionable. 

The following list of remedies, formulated by Prof. W. D. 
Miller from personal experimentation, and first published in the 
"Independent Practitioner," June, 1884, indicates their relative 
antiseptic power, but is not by any means intended as a guide for 
choice in administration. It gives the dilutions in which each 
will, under favorable circumstances, limit the growth of micro- 
organisms: 



10 



ORAL PATHOLOGY AND PRACTICE. 



Mercuric Iodid, 


i part in 200,000 


Mercuric Bichlorid, 


100,000 


Silver Nitrate, 


50,000 


Hydrogen Peroxid, 


8,000 


Tinct. Iodin, 


6,000 


Iodoform, 


5,000 


Naphthalin, 


4,000 


Salicylic Acid, 


2,000 


Oil Mustard, 


2,000 


■Benzoic Acid, 


1,500 


Potassium Permanganate, 


1 ,000 


Oil Eucalyptus, 


600 


Carbolic Acid, 


500 


Hydrochloric Acid, 


500 


Borax, 


350 


Arsenic, 


250 


Zinc Chlorid, 


250 


Lactic Acid, 


125 


Sodium Carbonate, 


100 


Listerine, 


20 


Alcohol, 


10 


Potassium Chlorate, 


8 



The disinfectants act chiefly through their ability to 
decompose offensive products. This is usually brought about 
by the presence of free oxygen, or that which is held in loose 
combination. Chlorinated solutions are effective through their 
ability to decompose water, thus setting free one or more vol- 
umes of oxygen, which is really the agent of decomposition. 
Hydrogen peroxid is very widely employed in oral practice, 
because it so readily parts with its extra volume of oxygen. 
Pyrozone is a more permanent and abiding preparation of nearly 
the same character. Electrozone, which is a decomposed solution 
of ordinary sea-water, is very effective, and has the advantage of 
being entirely innoxious. It may be swallowed, or used on the 
most delicate tissues, without ill effects. It is produced by an elec- 
trolytic current, which decomposes the chlorids and bromids of 
the salts, changing them into hypochlorites and bromites, and 
these are most effective disinfectants. 

Deodorants are not necessarily chemical agents. They 
may merely be able to absorb noxious matter. An excellent one 



SEPTIC AND ASEPTIC CONDITIONS. IJ 

is pulverized charcoal, which has the power to absorb a number 
of times its own volume of deleterious gases. It thus acts also 
as a disinfectant. The deodorants most commonly employed by 
oral practitioners are drugs of such penetrating, though pleasant, 
perfume that they cover and mask the odors of putrefaction, though 
without in any way neutralizing or decomposing them. It is need- 
less to say that they have no special therapeutic value. 

Detergents are cleansing remedies which are some- 
times in demand. They have no particular medicinal virtue, 
but remove certain superficial deposits from tissue surfaces, or 
from wounds, ulcers, etc. Pure water is excellent for this pur- 
pose, or a solution of borax, of common salt, or of soap may be 
used. 

Suppuration is primarily the breaking down of the product 
of inflammation, and its infection by a special microbe. Whether 
the breaking down is due to the organism, or vice versa, was long 
a disputed question. Late investigations lead to the belief that 
it is infection that brings about the devitalization of the blood 
corpuscle's and the production of pus, and yet it has probably been 
conclusively established that it is possible for pus corpuscles to 
be produced without the presence of bacteria. Such a condition 
is, however, unusual, and it does not present all the character- 
istics of the suppuration induced by pyogenic organisms. 

Ordinary pus is composed of certain nucleolar cor- 
puscles that are indistinguishable from the white blood 
cells, and which are supposed to be dead leucocytes, the 
extravasated serum of the blood, and such broken-down 
tissue cells as may exist in a certain state of degeneration. 
This material is found infected with certain pyogenic fungi. The 
formation and presence of pus is accompanied with the pyogenic 
fever, and its presence in the tisssues may also, under favorable 
circumstances, be determined by fluctuation beneath the fingers. 
When it is formed within the tissues it makes its way to the surface 
by the readiest route, that of least resistance, through the process 
of rotting or breaking down of the obstructing tissue, and forms 
an abscess. The process of suppuration is essentially one of 
extrusion, or expulsion of effete or dead matter. That inocula- 
tion, or infection of healthy tissue with the suppurative bacteria 
will induce the formation of pus and the production of an abscess 
is thoroughly established. Hence, in all curative processes it is 

3 



l8 ORAL PATHOLOGY AND PRACTICE. 

essential to use the utmost care to avoid infection; and all the 
modern methods of antiseptic surgery are built upon the ability 
to control the growth of septic organisms. 

All of the pathogenic and pyogenic bacteria are very easily 
communicated, either by direct contact and contamination, or 
through their spores, which may be floating in infected air. 
Modern surgery is superior to that of a few years since in the re- 
sults obtained; surgeons have learned how to avoid and guard 
against septic infection. It is now known, for instance, that if 
erysipelas once makes its appearance in the surgical ward of a 
hospital, mere exposure to the contaminated air will be likely to 
induce erysipelatous inflammation in any patient, but especially 
those in an atonic or debilitated condition. 

Infection may be carried upon the hands, in the cloth- 
ing, or by instruments and implements. The surgeon who 
would now attempt even minor operations without the most strict 
aseptic precautions would be deemed unfit to practice his profes- 
sion. His hands must be most thoroughly washed, all impurities 
removed from beneath the nails, and they must finally be care- 
fully drenched with a sterilizing solution, that no contaminating 
fungi may be carried to a wound. Every instrument used must 
be kept in a sterilizing solution, and sponges and lints must be 
needfully rendered non-infectious. The ordinary clothing must 
be covered with clean linen garments, that are less liable to carry 
infection than woolen, and every article used must be scrupulously 
clean. 

The operative dentist, or oral surgeon, needs to exer- 
cise especial care in this direction. There is no mouth that 
does not contain some species of bacteria. Indeed, the presence 
of some of them seems essential to perfect health, because they 
exercise a distinct diastatic function, and thus in healthy condi- 
tions may assist in the process of digestion. The human mouth 
presents all the conditions favorable to the growth of the bacteria, 
because the debris from different kinds of food, especially of 
starches, is always present. The diastatic action of the saliva 
converts these into fermentable sugars, and thus presents the 
best medium for the proliferation of very many of the bacteria. 
Moisture exists in sufficient quantity, and the temperature is 
exactly that best suited to their development, and it is main- 
tained at a point as constant as could be secured in the most 



inflammation: its general characteristics. 19 

perfect incubator. Indeed, the human mouth is a more perfect 
growing-chamber for the breeding of germs than any that the 
ingenuity of man could possibly devise. Not only is the tempera- 
ture uniform and the media and moisture at the best, but fresh 
pabulum is constantly added, while Ihe by-products are promptly 
removed and neutralized, so that there is no limitation of growth 
through their formation. 

The importance of every antiseptic precaution on the 
part of the practicing dentist cannot be over-estimated. 
He frequently meets with pus in the oral cavity, with gangrenous 
pulps in teeth, and his instruments are almost constantly infected 
with septic organisms. These may be deeply buried beneath the 
debris between the leaves of burs and the serrations of files, so 
that mere rinsing in a sterilizing fluid will not sterilize, and infec- 
tion of perhaps the most loathsome character may be carried to 
the mouth of the next patient, unless scrupulous care is used. 
It is something more than a professional blunder when an operator 
will work in the presence of pus, or any infection, without subse- 
quently cleaning and sterilizing in the most thorough manner 
every instrument employed, by means of a specially devised 
apparatus, and the use of disinfecting agents, such as bichlorid 
of mercury, carbolic acid, potassium permanganate, formalin, and 
other solutions. 



CHAPTER VI. 

INFLAMMATION: ITS GENERAL CHARACTERISTICS. 

A careful study of the etiology, symptomatology, and pathol- 
ogy of the inflammatory process is of the first importance to the 
student in dental medicine, because with bacteriology it forms the 
basis of most degenerative changes. Nor is it only concerned in 
retrogression. If hyperemia is accepted as one of the early stages 
of the inflammatory process, it is an important factor in many 
physiological and progressive metamorphoses as well. Wounds 
are healed and lesions repaired through its agency in some of its 
many phases; it is thus an element in the building up, as well as in 
the tearing down of tissue. There are emergencies in which the 
oral surgeon or physician desires to invoke its aid, and he si mc- 
times deliberately incites its action. But to reach the success at 



20 ORAL PATHOLOGY AND PRACTICE. 

which he aims he must be able to control and limit it, to impede 
its action here and to further its energy there; at all times to 
check it before it shall reach a degenerative or infective stage. 
Unless the practitioner has a fair comprehension of this important 
process, he will always be at work in the dark, and his treatment 
of most diseased oral conditions will be wholly empirical. The 
student will not be able intelligently to investigate any of the dis- 
orders to which he hopes successfully to minister, without a careful 
preliminary study of inflammation. 

The most advanced of modern pathologists, while they have 
extended the field of observation, have materially simplified the 
nomenclature. They recognize many added phases which the 
inflammatory process may assume, but in the light of the most 
modern bacteriological research they acknowledge but one dis- 
tinct form, that being the infective. Up to the point of invasion by 
septic organisms they denominate the condition one of hyperemia. 
Until disease germs are communicated they declare there can 
be no breaking down of tissue, or of the elements of tissue. There 
may be failure to organize the embryonal constituents, but the 
disorganization of that which has been constructed can only take 
place after infection. Hence, according to their views, all of the 
early symptoms and phenomena which are usually classed as a 
part of the inflammatory process belong to hyperemia, and are 
indicative of a local plethora, or congestion. 

In this conception, and according to this nomenclature, 
inflammation is essentially a destructive process, and its initial 
point is the beginning of the disorganization of tissue. This 
hypothesis emancipates us from the old and absurd nomenclature, 
under which every different phenomenon exhibited by what must 
necessarily be a single process was given a separate name and 
classed as a distinct form of inflammation. Some writers have 
specified as many as fifteen kinds of this process, and treated each 
as a separate pathological condition. There has been no identity 
of view, and no harmony in description or terminology. There 
has been no universally accepted theory which might be adopted, 
but each pathologist has been in one sense a law unto himself, 
and has instructed according to his own views. 

If the most modern hypothesis shall be generally adopted, 
there is no doubt that it will materially simplify pathological 
instruction, and reduce to a comprehensible system much that 



inflammation: its general CHARACTERISTICS. 21 

has heretofore been incongruous and unintelligible. But in the 
preparation of a book to be used in teaching, extreme views should 
not be precipitately adopted. They are not likely to be in har- 
mony with the teachings of the other departments of a school, 
they are in conflict with instruction already given and with 
preconceived ideas, and until they can be generally adopted tend 
to produce confusion in the mind of the student, and are preju- 
dicial to that unity of theory and consecutiveness in thought 
which are essential to good tuition. It is infinitely better that 
the student in college should be given but one hypothesis, rather 
than a number of conflicting theories. When he is familiar with 
that, he may in practical life leave its limitations and modifications, 
and become acquainted with other views. 

This work, then, while fully recognizing the reasonableness 
of the most modern theories concerning inflammation, will not 
fully adopt their nomenclature, but will follow the usually accepted 
views, modified to a certain extent by the indisputable facts estab- 
lished by the most modern research. 

Inflammation may be defined as a disturbance of nutrition in 
a tissue or organ, primarily characterized by hyperemia and accom- 
panied by certain definite symptoms. Its immediate cause is irrita- 
tion of some kind, and its ultimate source is a nervous shock, 
manifested either directly or by reflex agency. Its primary mode 
of action is through the blood current, and the early changes 
induced by it are in the blood vessels. That the student may 
comprehend this, it is necessary clearly to define some of the 
terms used, and to indicate in what sense they are employed. 

Plethora is that state in which there is an abnormal fulness of 
the blood vessels; a superabundance of blood; an undue increase 
in the entire mass of the blood in the system. 

Anemia is the converse of this. It is a state in which there is a 
deficiency of the blood as a whole, but especially a lack of the red 
blood corpuscles, and hence a condition of depression of the tone 
of the system, and of enfeebled nutritive ability. 

Hyperemia is a local plethora or congestion of blood. Its special 
seat is in the capillaries. 

Ischemia is a local anemia. It implies a lack of nutrition in a 
part, as anemia does in the general system, because the supply of 
blood is for some reason insufficient. 

Hyperemia implies an alteration in the velocity of the 



22 ORAL PATHOLOGY AND PRACTICE. 

current of the blood in both veins and arteries. It also 
includes a variation of the blood vessels in their character 
or tone, their nutritive power being modified. There is a 
change in the condition of the coats of the smaller arteries and 
veins; they assume a state either of tenseness or laxity that is not 
normal to them. They become turgescent. The color of the 
blood in the veins is changed, by modifications of nutrition. It is 
no longer of a dark or venous color, but more nearly approaches a 
bright arterial hue, due to its inability to perform its true function 
and exchange its oxygen for the carbon dioxid that is the result of 
the degenerations of tissue due to wear. There is a partial obstruc- 
tion of the current in the arterioles, and they may even begin to 
pulsate with the larger arteries. Both veins and arteries become 
distended with the increased flow of blood. The blood corpuscles 
are greatly increased in number and modified in tone. 

If the irritation that has produced this condition in the 
tissues is not continued, the disturbance will be but tem- 
porary, and will soon subside. The system recovering from 
the nervous shock, the blood vessels will soon regain their normal 
tone, the vascular fluid will begin to flow in its wonted manner, the 
congestion of the capillaries will be relieved, and the hyperemic 
condition will pass away. 

It has already been affirmed that it is the nervous shock 
produced by the action of some irritant which induces the 
change in the condition of the arteries and veins that 
accompanies active hyperemia. Technically it is not the bullet 
in the heart that kills. It is the nervous shock caused by the 
irritating bullet. The knife stab injures certain tissues that are not 
vital. But in so doing it produces a nervous impression that is so 
profound as materially to interfere with the processes of life which 
are vital, function ceases, and that is death. It was not the wound 
that killed, but the markedly depressing influence which it induced 
upon organs themselves untouched. It is necessary to keep this 
distinction carefully in mind in the consideration of inflammation. 

Shock may be produced by either direct or reflex nervous action. 

By direct, zee mean the irritation that is produced by actual injury 
to the terminal nervous filaments themselves. Thus a blow upon the 
cheek will induce a redness, or hyperemia in the capillaries of the 
tissue that received the irritation, and whose nerve filaments were 
really harmed. 



CHANGES ATTENDING THE INFLAMMATORY CONDITION. 23 

By reflex nervous action, we mean that in which the impulse is 
carried by one set of nerves to another set, thus producing its effect at a 
distance from the seat of irritation. The influence of an irritant may 
be carried by an afferent, or sensory nerve, to some great center, 
where it will be transmitted to an efferent, or motor nerve, and the 
stimulus carried along its course until it reaches the tissue supplied 
by it, and it may be upon this that the characteristic effect will be 
indicated. Or the effect of the irritating agent may be received 
by one afferent .nerve and reflected to another of the same system, 
the subjective sensation, with the local effects, thus being made 
manifest at some distance from the point of injury. The blush that 
is brought to the cheek of the sensitive young maiden by an in- 
delicate remark is the same kind of transient hyperemia that is 
produced by a blow of the hand. Yet in the former case there is 
no real impact, no positive injury, no actual lesion of any kind. 
But the hyperemia will probably be more pronounced and marked 
than when the nervous action is direct. The face will blanch 
under the influence of fear, when no direct impact could produce 
this effect. The hair will stand erect through reflex action caused 
by intimidation, a state that no voluntary action could bring about. 
People drop dead at the communication of profoundly affecting 
news, which acts in a reflex manner. Indeed, instant functional 
cessation and death are more complete and frequent in cases of 
shock from reflex than from direct injuries. The influence of 
external and surrounding impressions upon sick people will not 
infrequently completely neutralize the effect of medicinal agents. 

Profound anesthesia cannot readily be obtained in peo- 
ple with unusually responsive nerves, unless external 
irritation and interference is cut off. It would appear, then, 
that of the sources of irritation that may produce hyperemic condi- 
tions, those that are derived through reflex nervous action are the 
more important, and should be most carefully guarded against. 



CHAPTER VII. 



CHANGES ATTENDING THE INFLAMMATORY 
CONDITION. 

The changes in the veins and arteries that induce a condition of 
hyperemia are produced through the vaso-motor nerves. These 



24 ORAL PATHOLOGY AND PRACTICE. 

are derived both from the cerebro-spinal and the great sympa- 
thetic systems. They are the terminal filaments whose special 
function it is to govern and keep in proper relation the coats of 
the blood vessels to which they are distributed. Upon the larger 
vessels they form intricate plexuses, sending out single filaments, 
or bundles of filaments, which twine about the vessels, penetrate 
their external coats, and are principally distributed to the muscular 
tissue of the vessel, and by their action in contracting or relaxing 
the artery or vein they govern the amount of the blood-flow. 

There are presumably two kinds of nerves in the vaso- 
motor system, one being the constrictors and the other the 
dilators. It will readily be seen, then, that either may be excited 
and the caliber of the vessel modified accordingly. Nor is the 
amount of blood necessarily and completely gauged by the question 
as to whether it is the dilators or the constrictors that are excited 
to action. There may be a lessening of the caliber but a retention 
of the elasticity of the muscular fibers that will result in a great 
increase of the velocity, and this may have a tendency to wash 
away any obstructions in the blood channels. On the other hand, 
there may be a dilatation with a loss of tone and a complete rigidity 
of the muscular coats that will eventuate in a reduction of the 
velocity as well as in the amount of blood conveyed. 

There may be a contraction of the vessel, with a con- 
dition of such tonicity as will greatly augment the amount 
of the circulatory fluid carried, or there may be almost a 
complete stagnation of blood in a greatly relaxed artery or 
vein. It may be readily seen, then, that the tone of the walls of the 
vessels has very much to do with the blood supply. Through the 
reaction of the vaso-motor nerves, the very character of the coats 
of a vessel may be materially modified, so that instead of retaining 
their contents they allow a part to escape through the meshes. 
The different coats may become so relaxed, that through their 
walls the red or the white blood corpuscles, or the serum of the 
blood, may readily exude, and so pass out into the surrounding 
tissues, infiltrating them and producing the symptoms which 
attend the condition that is commonly called the inflammatory 
state. All these changes must be massed in the consideration of 
the inflammatory process. 

The first stage is hyperemia, or an increased blood supply through 
modification of the caliber of the coats of the blood vessels. 



CHANGES ATTENDING THE INFLAMMATORY CONDITION. 25 

The second stage consists in the further changes in the condition 
of the coats of the vessels, by which they become so modified as no longer 
perfectly to retain all their contents. 

The third stage is the modifications produced in the tissues through 
the extruded contents of the blood vessels, for the blood having once 
passed out cannot enter them again, but must be otherwise disposed of. 
This stage necessarily includes the degenerative processes taking 
place in the products of inflammation which result from infection. 

It should be comprehended that the mere change in the caliber 
of the vessel forms no necessary part of the inflammation, which 
may terminate with the simple hyperemia. But the third change, 
that in the vessels, which so modifies them that they no longer 
retain their contents, produces a more profound impression, and 
materially affects the tissues supplied by them. When this 
extravasated matter becomes infected with pathogenic or pyogenic 
micro-organisms, that impression is intensified, and degenerative 
processes are set up. This is an active state of inflammation, in 
which all the nutritive processes of a part are engaged. 

There are certain symptoms that are peculiar to inflammation 
and which always attend it in a greater or less degree. They are 
heat, redness, swelling, pain, and usually a general febrile condition. 

The first of these, heat, is due to a number of factors. 
The deeper portions of the body have a higher temperature than 
those that are superficial and are exposed to external cooling 
influences. When the blood quickly reaches the periphery it will 
lose less of its heat than when it makes its way more gradually. 
Hence, in the increased velocity of inflammation, the surface has 
more of the heat of the internal portions of the body. 

Again, this very velocity generates a certain amount of heat by 
the increased friction. There is also some increased oxidation, 
and this adds to the higher temperature. All of these factors 
together account for the increased local heat of inflammation. 

The redness is due to the hyperemic condition, the 
increased amount of blood in the part, and the unchanged 
color of the venous circulation. The intensity of the change 
will depend upon several factors. The amount of the local dis- 
turbance, the thickness of the superimposed tissues and their 
degree of translucencv will all have an influence. Persons with 
thin, transparent skins show the superficial hyperemic condition 
much more plainly than others. 



26 ORAL PATHOLOGY AND TRACTICE. 

The swelling is the effect of the diapedesis, or escape of 
the elements of the blood through the walls of the vessels, 
because of their changed condition under the irritation 
manifested through the vaso-motor nerves. The tissues are 
thus infiltrated and distended. The amount of this dilatation or 
extension will depend upon the nature of the tissue in which it 
takes place, and upon the character of the functional disturbance. 

The pain is the effect produced upon the terminal 
nervous filaments by the deranged condition, and the pres- 
sure of the exudate. Sometimes this will be of a throbbing 
character, clue to the pressure exerted by the arterioles at each 
heart contraction, or systole, upon the already irritated and sensi- 
tive terminal nerve filaments. Boring pains are usually connected 
with inflammations of bone tissue. Lancinating pains ordinarily 
accompany acute swellings, and are indicative of a ripening 
abscess. Soreness is due to the formation of an abscess cavity in a 
very sensitive tissue or organ. That of a boil, which is an instance 
of suppurative inflammation, is proverbial. 

The general fever is the result of the sympathy of other 
organs with that which is directly affected. It is the office 
of the nervous system to preserve the equilibrium of the various 
functions of the body. When this is disturbed by an aberration ex- 
isting in any organ, all the others suffer in a greater or less degree, 
and thus is produced a general feeling of malaise or discomfort. 

The causes which excite an inflammatory condition are divided 
into predisposing and exciting. 

Predisposing causes arc special conditions of the body, which 
render the organs or tissues more liable to take on the pathological 
conditions. In the presence of predisposing causes, comparatively 
slight irritation may result in serious disturbances. A state of 
atony, or asthenia, or general debility, reduces the resistive force of 
the tissues and promotes the invasion of disease. Anemia is 
another predisposing cause, the poverty of the blood, or the lack of 
certain of its elements, seriously interfering with that nutrition 
which must maintain the general tone. 

The exciting causes of inflammation are very many, and include 
whatever may produce shock, such as cold, heat, traumatism or 
injuries, etc. A common cold is an inflammation induced by sub- 
jecting one part of the body to a sudden diminution of its tem- 
perature, and thus disturbing the general nervous equilibrium or 



FURTHER DEGENERATIVE CHANGES. 2*J 

tone. Many chemical substances are nervous irritants, either 
through direct or reflex action. Poisons act in this way, and these 
include the stings of bees, the bites of many insects, and the pecu- 
liar effect of certain vegetables, such as poison ivy and oak. 

Many of the pathogenic micro-organisms induce a state of inflam- 
mation through their growth in the system. All lesions, wounds, and 
injuries give a shock that is more or less profound, and thus bring 
about inflammatory conditions. 

A cachectic state, or dyscrasia, is either one of disturbed 
general nutrition, or of local degeneration, that makes the 
organs liable to inflammation, as in gout, calculus, etc. 

It has already been affirmed that a nervous shock that affects 
the vaso-motor system may so change the condition of the blood 
vessels as to permit the escape of a portion of their contents. John 
Hunter recognized the intimate connection of the blood current 
with inflammatory processes, and declared that hyperemia and con- 
gestion were their initiative stages. Less than thirty years ago, 
Cohnheim published the results of a series of observations that 
gave the world a new insight into the pathological changes that ac- 
company this disturbed condition, especially in the earlier modifica- 
tions. Other pathologists have carried the explorations further, 
and some of them have dissented from a part of the conclusions of 
Cohnheim, but his general deductions are accepted as correct by 
most pathologists. 



CHAPTER VIII. 

FURTHER DEGENERATIVE CHANGES. 

If the mesentery of a frog is exposed to the air and placed 
under a microscope, it will be seen that the flow of blood in the 
capillaries is greatly augmented. They arc distended, and many 
that had been invisible are by this dilatation brought into view. 
The leucocytes, or white blood corpuscles, arc gradually increased 
in number. Regions in which there normally appears only an 
occasional one, soon become thronged with them. The increased 
velocity of the current lasts but a short time, when the flow begins 
to be retarded, and is soon slower than the normal, the distention 
still remaining. A partial stagnation succeeds, and the while 
corpuscles begin to accumulate in the small veins and arteries, and 



28 ORAL PATHOLOGY AND PRACTICE. 

show a tendency to cling to the walls. They are swept back into 
the lessening current, but soon find another point of attraction, and 
finally remain attached to the lining surface. They soon become 
so enormously increased that the inner surface of the vessels is 
completely covered with them. In the capillaries and arteries the 
white corpuscles are mingled with the red, and do not accumulate ' 
in such great numbers, but in small veins they seem to have become 
separated from the red and to cling in greater numbers. 

Soon they begin to alter their appearance, and to exercise 
their peculiar ameboid, or spontaneous change-of-form movements. 
The vessel wall remaining distended, after a little time there is ob- 
served upon its external surface a minute protuberance, which 
momentarily increases, the cell opposite upon the internal wall 
correspondingly diminishing, until it is seen that the whole of the 
jelly-like protoplasmic 'leucocyte has penetrated the walls, and 
been extruded upon the periphery. At the same time with the 
changed condition of the vessel walls, other of the contents have 
passed through and invaded the surrounding tissues. Some of 
the fluid portions of the blood — the liquor sanguinis, composed of 
serum and the substances that go to make up. fibrin — are found in 
the irritated tissues. The fibrinous elements spontaneously unite 
and form fibrin, and mingled with these will be found the leu- 
cocytes. These last have been considered as the active agents of 
repair, themselves forming the initial or germinating point in the 
organization of the plastic exudate into tissue. This hypothesis 
seems most consistent with known facts, and offers a ready explan- 
ation of some phenomena not otherwise comprehensible. 

It is but proper to say that this theory is not accepted by some 
histologists and embryologists, who consider the leucocytes but as 
scavengers for the removal of offensive matter. 

That the leucocytes have a digestive power, appropriating 
bacteria, has been shown by a number of observers. They may 
also be useful in consuming portions of broken-down tissue, and 
hence assist in the absorption of blood-clots, exudations, etc. But 
that this is their sole office does not seem congruous or compatible 
with demonstrated truths, and it is not accepted in this connection. 

The number of leucocytes is notably increased during inflam- 
mation. They may be seen to gather in great numbers in the 
smaller vessels, and they migrate in profusion into the surrounding 
tissues. Their origin is yet in dispute. It was formerly held that 



FURTHER DEGENERATIVE CHANGES. 20, 

their multiplication was due to increased cell proliferation or for- 
mation under the stimulus of the inflammatory process. But Yon 
Recklinghausen found in connective tissue two kinds of cells, 
which he called the fixed and the wandering. The former he says 
are stationary among the fibers of the intercellular substance, and 
are round, or spindle shaped. In addition to these he observed 
•other cells, in all respects resembling the leucocytes, which take on 
spontaneous changes of shape by means of the extension of a 
portion of their jelly-like substance (pseudopodia — false feet), such 
as are characteristic of the ameba, and hence called ameboid move- 
ments. By means of these mutations they constantly changed 
their location, passing through the meshes of the lymph canals, 
entering from the blood and escaping through the lymphatics, thus 
keeping up a constant circulation. In normal tissues they were 
few in number, but in the presence of irritation or inflammation 
they were inordinately multiplied. 

This is the generally accepted theory of to-day. The wander- 
ing cells of Yon Recklinghausen are the white blood corpuscles, 
which even in entire health are escaping through the walls of the 
blood vessels in small numbers, and by their ameboid movements 
they traverse the tissues until taken up by the lymphatics and 
carried out. Their probable generation is in the lymph glands or 
nodes, the spleen, etc., and in inflammatory conditions they are 
enormously increased, and are carried by the blood to the disturbed 
territory, whence they readily pass into the tissues through the 
changed condition of the vessel walls. Their multiplication in an 
inflamed tissue is in proportion to the violence of the disturbance. 

Corresponding to this increase in the number of the 
white blood corpuscles in the tissues is the extravasation 
from the blood vessels of the fluid portions, or the blood 
plasma. The fibrinogen which this contains, coming in contact 
with the ferment, or paraglobulin of the leucocytes under their 
changed condition, fibrin is formed, and the lymph is coagulated 
or fixed in the tissues. The product thus formed, with the 
emigrated blood cells, composes that which is know n as the "plastic 
exudate," and it is the progressive or degenerative changes in this 
substance that constitute the further phenomena of inflammation. 

The plastic exudate once having been formed in the tissues, it 
may assume such a complete fibrillation, such an entire conversion 
into a dense compact fibrin, as to produce that which is called an 



30 ORAL PATHOLOGY AND PRACTICE. 

induration. This at times assumes to the fingers almost the hard- 
ness of bone. In inflammation of the tissues about the jaws it is 
not infrequently mistaken by the novice for bone, and a wrong 
diagnosis is accordingly made. It may be immovable, without 
special sensation or pain, and apparently closely attached to the 
osseous tissue. In this form the plastic exudate is persistent and 
indolent in its character, and does not readily degenerate nor 
assume a progressive aspect. It may disappear under the slow 
process of gradual resorption, or it may eventually break down. 



CHAPTER IX. 

THE PRODUCTS OF INFLAMMATION. 

The methods by which the plastic exudate, or the coagulable or 
fibrous lymph, and the remaining products of inflammatory condi- 
tions may be disposed of, are by (1) Resolution," (2) Building up, 
(3) Tearing down. 

Resolution means the taking up of the products by the absorbents, 
and their disposition through the lymphatic system. There is a 
cessation of irritation, the blood vessels return to their normal 
condition, exudation ceases, and there is a gradual return to a 
true physiological state, as there is when hyperemia alone exists 
and the disturbance does not extend to the point of active inflam- 
mation. 

Building up of tissue means that the plastic exudate has been 
by regular progressive changes organized into tissue of an embryonic 
character. The methods of this metamorphosis are — 

(a.) First Intention. — This implies a regular progression from 
the commencement, without any degenerative changes whatever. No 
pus is formed, nor is there infection by micro-organisms. The 
term "healing by first intention" is usually applied to wounds, 
either traumatic or surgical, especially to those of an incised 
character. If the gaping produced by the elasticity of the tissues 
is closed, and the severed parts brought into nice coaptation, 
either by stitches, adhesive plaster, or finger manipulation, the 
fibrin that is formed by the plastic exudate agglutinates or cements 
them together, and union without any violent or disruptive 
inflammation may ensue. This can only be secured by thoroughly 



THE PRODUCTS OF INFLAMMATION. 3 1 

aseptic conditions, and it is this at which all surgeons aim in their 
treatment after operations. 

fb.) Granulation, or Second Intention.- — This is the building 
up of the tissue, or the organization of the exudate by means of papilla, 
or grain-like growths, that spring up from the base of healing 
wounds. It is a progression cell by cell, instead of organization 
more in mass. Capillary loops are formed in the extravasated 
plasma, which as it is poured out will be found shielded by a kind 
of transparent glistening film, that protects it until the lost tissue 
has been restored, and the skin shall have been formed over it. 
This new growth is known as granulation tissue, and is always 
of a cicatricial or elementary character. The new formation is 
primarily of the connective tissue variety, and is subsequently 
modified into that of which it forms a part. 

The organization of the tissue, when it proceeds without any 
degenerative processes, may be clinically studied in the socket 
from which a tooth has been extracted. The cavity will at first 
be found filled with coagulated blood, which effectually seals the 
mouths of the ruptured vessels. Within a very few days at the 
most, this will have been sloughed away, and the socket of the 
root will be found occupied by a kind of translucent, jelly-like 
substance, which is very easily wiped away with a pledget of 
cotton. If it is left undisturbed a short time longer, it assumes 
a firmer consistency and becomes opaque and of a whitish 
color. This is the plastic exudate that has been effused. It now 
cuts like gelatin, and has the same general appearance. Another 
day, and if it be divided with an excavator or the point of a sharp 
bistoury, a minute drop of blood will ooze out. This indicates 
the formation of blood channels within the mass. There is no 
continuance of blood flow, for circulation has not yet been estab- 
lished, but minute sinuses have been formed, and they are filled 
with sanguinary fluid. In yet another day or two these will have 
I mti line connected with the blood channels of the surrounding 
tissues, and a form of circulation will have hern established. The 
exudate is now firmer, and cuts like new, partiall) formed carti- 
laginous tissue. The mucous membrane ami epithelia form over 
it, an<l it assumes the appearance of the surrounding gums. Then 
commences the process of calcification, and soon the knife feels 
!li<- grating of formative bone. Calcification proceeds until the 

cavity is completely filled with well-organized bone tissue. This 



2,2 ORAL PATHOLOGY AND PRACTICE. 

peculiar form of healing by first intention will not be observed 
except in cavities that are well protected from external violence. 

If this kind of formative tissue in its early periods of develop- 
ment is examined under a microscope, it will be found filled with 
small round cells, which gradually assume a spindle form, and 
the deepest layer will be found composed of bundles of them. 
This is a part of the process of the formation of embryonal tissue, 
which gradually is developed into that of a more perfect type. 
The cicatrix is connective tissue that has contracted in the course 
of its formation, and which thus tends to draw together the edges 
of a wound, but which may be so excessive as seriously to inter- 
fere with function, as is the case in extensive burns. The surgeon 
accomplishes this coaptation of the borders of wounds by means 
of sutures. 

When by means of a continuance of the irritation the inflam- 
matory process is exacerbated, or when new sources of irritation 
are introduced, the healing- process is interfered with and the 
plastic exudate, instead of being organized into tissue, loses . its 
integrity and is broken down, involving the investing tissue. This 
may be by (1) Suppuration, (2) Gangrene, (3) Necrosis. 

Suppuration is the formation of pus. The exudate, from con- 
tinued irritation or from a lack of nutrition, loses its organizing 
power, becomes infected by pyogenic micro-organisms, degen- 
erates, and forms pus. The leucocytes, or white blood corpuscles 
that have migrated to the inflamed territory, die and become the 
characteristic pus corpuscle. The plasma melts down and is 
mingled with the extravasated serum of the blood. The tissue 
in the immediate neighborhood is infected, degenerates and 
breaks down, and a pus cavity is thus formed. 

Pus is essentially a foreign substance, and Nature puts 
forth her utmost efforts to expel it from the system. The 
pressure is considerable, and the tissue in the line of least resist- 
ance yields and becomes disorganized, thus extending the pus 
cavity, usually toward the periphery or some natural cavity of 
the body. This continues until it is discharged upon the surface 
and an abscess is formed. The determination of this destructive 
process toward the place of exit is called the "pointing" of the 
abscess. 

If the irritation has now ceased, as in the case of the extru- 
sion or removal of some foreign substance that was in the tissues, 



■ \ 



THE PRODUCTS OF INFLAMMATION. 33 

the process of healing commences, and may proceed by granula- 
tion until the lesion has been completely restored. If the irritant 
is not carried away by the first suppuration, the process will be 
repeated. In alveolar abscess arising from irritation and infection 
of the pericementum of a dead tooth, the plastic exudate will be 
effused about the point of infection, only to be infected in its turn, 
and to break down with new formation of pus. At first these- 
pointings will be periodical. They may be precipitated by any 
general inflammatory condition, and follow upon the so-called 
taking of a cold. After a time the condition becomes chronic. 
There is a steady effusion of the exudate, and it is as regularly 
infected and broken down, and thus an almost continuous dis- 
charge of pus from the sinus formed is the result. 

Pus was formerly classed as laudable or healthy, 
serous, sanious, ichorous, etc. We now know that the thick, 
creamy, opaque, yellowish discharge, which was formerly denomi- 
nated laudable pus, is the uncontaminated, undecomposed dis- 
charge from a healthy person, or from a surface in the process of 
normal healing. 

Ichorous pus is the thin and acrid ejection from an ulcerative 
surface, or is that which has passed through a second degenerative 
process. 

Sanious pus is that which is mixed with blood, and which partakes 
of the nature of both. It is usually an indication of a destructive 
action, and of the cellular sloughing that accompanies the breaking 
down of tissue. It may be ichorous in its character. 

Serous pus is that which is mixed with serum from the blood. 
It differs from sanious pus, in that it is more simple in its nature, 
and is not an indication of putrefactive changes. 

Muco-pus is that which is mixed with the secretions of the mucous 
glands. Tin's is probably but an accidental complication, and the 
character of the pus is not thereby materially changed. It does not 
imply that there has been any secondary infection with destructive 
organisms, or any putrefactive degenerations. 

Gangrene is also known as mortification, and when sloughing 
takes place, as sphacelus. It is the cessation of all nutrition in a 
territory more <>r less considerable and circumscribed, with a conse- 
quent loss of function and death in mass. Its origin may be in a 
traumatism or wound, in a local cause like thrombus or embolism, 
in continued pressure either external or internal, in the too free 

4 



34 ORAL PATHOLOGY AND PRACTICE. 

use of certain drugs, such as ergot, phosphorus, mercury, or 
carbolic acid, and finally in constitutional causes, such as diabetes 
or anemia. It is usually divided into moist and dry, or senile, 
gangrene. When the degenerative changes which succeed loss 
of nutrition in a part have commenced, there may be an infection 
with certain bacteria of decomposition, and the whole territory 
become highly aseptic. The tissue is in a putrefactive state, and 
auto- or self-inoculation in other tissues may be the result. 

In addition to these septic conditions of gangrenous degen- 
erations, the disease may be the direct result of infection. There 
are special types, due to the activity of micro-organisms, that have 
long been distinguished as phlegmonous erysipelas, malignant 
edema, hospital gangrene, noma, etc. Hospital gangrene is now 
almost unknown, its disappearance as a separate affection being 
due to our increased knowledge of septic conditions, and to anti- 
septic precautions and treatment. 

Dry or senile gangrene presents a very marked difference 
in its objective appearance to the moist type. As its name indi- 
cates, it occurs usually in old people, being seldom found in those 
under fifty years of age. It is usually caused by arterial disease 
or degeneration, through which the circulation in a part is cut 
off. The part being deprived of blood, the moisture is lost by 
evaporation, and there is a consequent shrinking and wrinkling 
of the tissues, which produces that peculiar appearance called 
mummification. If from the outset putrefaction is prevented, the 
type of gangrene is always dry. 

This affection may usually be readily diagnosed. The pecu- 
liar appearance of the tissues, with the odor of putrefaction, in 
moist gangrene, and the coldness, dryness, and pallor of dry 
gangrene, seldom leave the surgeon in doubt as to the nature of 
the affection. 

Necrosis, which in its general signification means the death of a 
part, may be properly used to include gangrene. In its surgical 
employment the term is nozv restricted to death of the hard or bonv 
tissue. It is the analogue of gangrene in soft tissues, and it has 
the same general etiological origin. It is the stoppage of the 
nutritive currents, with the consequent death of the part. From 
the nature of the tissue in which it exists, its progress is nat- 
urally slower than is that of gangrene, but the tendency is the 
same, and it should end in the sloughing away of the dead part 



GENERAL TREATMENT OF INFLAMMATION. 35 

from the living. When such a necrosed portion of a bone is 
thus separated, it is called the sequestrum. Of all the bones of 
the body the inferior maxillary is most apt to take upon itself 
necrosed conditions. This is partly because it is more subject 
to accidents than most bones, but chiefly because from its pecu- 
liar connection with the rest of the body, its great mobility and 
the constant and violent uses which it is made to subserve, nutri- 
tion is the more readily interfered with. About three cases of 
necrosis of the lower jaw occur to one of the upper. 

It will be seen, from a retrospective view of the preceding 
statements of the condition called inflammation, that it is, as was 
affirmed at the outset, the initial point of very many changes in 
the body, of a physiological as well as of a pathological nature. 
It commences with simple hyperemia, and ends with the final 
disposal of the plastic exudate by either progressive or retro- 
gressive metamorphosis. It is the result of an irritant, which 
produces a more or less profound impression upon the tissues 
through the nervous shock. The vaso-motor system is so dis- 
turbed as to modify the conditions of the blood vessels in the 
neighborhood of any lesion, and to permit the passage into the 
tissues of their contents, through diapedesis. This extravasated 
matter is the plastic exudate that is either organized or disorgan- 
ized, and it is the result of the earlier stages of the inflammatory 
process. 

The termination of inflammation, then, is either in the 
building up of the plastic exudate into new tissue, by first 
intention or by granulation, or in its degeneration and 
tearing down by suppuration, gangrene, or necrosis. The 
final result depends upon the degree of the lesion or injury, upon 
external sanitary or unsanitary surroundings, upon constitu- 
tional tonic or atonic conditions, and upon the ability to maintain 
the circulation practically unimpaired. 



CHAPTER X. 

GENERAL TREATMENT OF INFLAMMATION. 

Tin. treatment <>f inflammatory states will necessarily be 
largely general in its character. The various remedies to be 
employed may !>«.• classified as follows: 



36 ORAL PATHOLOGY AND PRACTICE. 

For the heat — Reduce the temperature by refrigerants. 

For the swelling — Use compression: apply bandages. 

For the hyperemia — Use depletion : leeches, cupping, etc. 

To produce metastasis — Counter-irritants, blisters, etc. 

To relieve circulation — Cathartics, diaphoretics, diuretics. 

To equalize the circulation — Hot pediluvia (foot-baths). 

For the fever — Febrifuges, antiphlogistics. 

For the pain — Sedatives, anodynes, local anesthetics. 

To promote suppuration — Warmth, moisture, poultices. 

The first remedial measure to be employed will of course be 
the removal of the cause of the irritation, provided this can be 
definitely ascertained. The next will be to give rest to the parts. 
The latter is best secured by immobility and entire repose. All 
use of the affected organ should cease, and it should be placed 
in the easiest position possible. Saline cathartics may be adminis- 
tered, with the view of relieving the tension of the blood vessels 
by a depletion of their watery contents. Diuretics are useful for 
the same reason. If a laxative only is desired, Seidlitz powders 
may be prescribed, or mild doses of castor oil. For a saline 
cathartic, Epsom or Rochelle salts (magnesium sulphate, sodium 
tartrate), or cream of tartar (potassium bitartrate), may be 
employed. "But still more efficacious are diaphoretic remedies, 
because they not only remove the water of the blood and tissues 
but act as refrigerants, through evaporation from the surface. 
They also tend to depuration by opening the pores of that great 
eliminative organ, the skin. Dover's powder, or spirits of Min- 
dererus, with warmth and diluent drinks, may be used. In general 
forms of inflammation, febrifuges, such as potassium chlorate, 
quinin, antipyrin, and antifebrin, should be administered, and the 
general hygiene should be carefully looked to. If there is general 
irritation, sedatives, either arterial or nervous, as may be indicated, 
should be given. 

If the inflammation shall have proceeded to the point of 
effusion of its products, early efforts are usually directed toward 
bringing about resolution, or absorption of the lymph. 

Local cupping or bleeding may be useful, although the best 
means for securing local depletion will usually be by the applica- 
tion of leeches. These agents, which have of late been almost 
entirely abandoned, will often prove of greatest efficacy. In addi- 
tion to the general remedies recommended, counter-irritants may 



GENERAL TREATMENT OF INFLAMMATION. 37 

be employed. These induce a change in the location of the 
inflammation by metastasis, or the production of a new point of 
irritation, with the consequent transference of the seat of diseased 
action. 

Park recommends in forms of phlegmonous infiltration the 
application of an ointment composed of resorcin 5, ichthyol 10, 
mercurial ointment 3, and lanolin 50 parts, as a sorbefacient and 
antiseptic preparation. This in connection with moist heat may 
even secure the actual resorption of pus. 

If there is local swelling, it may sometimes be controlled 
by bandaging, which prevents further effusion and promotes the 
absorption of that which has already taken place. It is not, 
however, usually convenient to apply a bandage or excite much 
pressure upon any of the oral tissues. 

If there is considerable local heat, it may be controlled by 
the application of ice, or by the ether or alcoholic spray. 

If neither resolution nor building up of tissue seems possible 
or probable, efforts should be directed toward the promotion of 
suppuration, thus relieving the tissues of the products of the 
inflammatory process. It is here that the oral physician or sur- 
geon will have an opportunity for the exercise of his best judg- 
ment, and all his experience will be needed in making his prog- 
nosis, to determine the exact point at which the treatment should 
be changed. To ascertain when the degenerative process has 
begun, requires the nicest perception and discernment. In 
inflammation of the dental pulp, for instance, to know when it 
is no longer wise to attempt to preserve its vitality, and when 
devitalization and extirpation are advisable, in view of positive 
degenerative changes that are imminent, requires a thorough 
knowledge, not only of the whole inflammatory process, but of 
the symptomatography.of all the lesions and complications as well. 
The breaking down of tissue' having already commenced, or 
being plainly inevitable, suppuration should be hastened, that the 
more destructive processes of gangrene and necrosis may not 
supersede it. Poultices should at once be employed in the direc- 
tion in which it is desired that the abscess shall break. This 
promotes suppuration by extending such favorable conditions as 
are afforded by a maintenance of the temperature, the continued 
presence of moisture for the softening of the ti>>ucs, and the dila- 
tation of the vessels. Any poultice that will secure this will suffice, 



38 ORAL PATHOLOGY AND PRACTICE. 

although if it is of a fermentative substance, that process will assist 
in the weakening of the superincumbent tissues. 

It is not convenient to use for oral application the poultices 
commonly employed in general medicine. A freshly cut fig or 
a split raisin may often be applied when no other can, and they 
act very effectually. They should usually be softened and warmed 
by dipping in hot water. They are pleasant to use in the mouth, 
and when one piece becomes too much softened another is readily 
substituted. They will usually be held in place by the facial 
muscles. 

There are certain general remedies that promote suppuration 
under definite conditions, but they are little adapted to oral prac- 
tice. In the treatment of inflammation the aim should always be, 
after diapedesis has taken place, to relieve the tissues of the exu- 
date material, and to promote healing when there has been any 
traumatic wound or lesion. 

Whenever pus is present it must be promptly evacuated. 
There is no precept in practice that is so imperative as the one 
which instructs the practitioner at once to get rid of pus. There 
is no surgical risk that one is not justified in taking if this product 
can be eliminated in no other way. It is always irritative, always 
degenerative, in its influence. Sometimes a mere puncture will 
evacuate it. at other times a serious operation is demanded; but, 
whether simple or complicated the means of elimination, it must 
not be permitted to remain. Some judgment may be required in 
securing perfect drainage if an opening is made, and this demands 
that the artificial sinus shall be at the lowest, most dependent point 
when the body is in its natural position. Drainage tubes may be 
demanded; or gauze, catgut strands, or other media may be used 
to keep the opening patulous. These may be retained in position 
by strips of adhesive plaster. 

After evacuation the pus cavity should be cleaned and disin- 
fected with hydrogen dioxid, pyrozone, or some other effective 
antiseptic or disinfectant solution. The utmost care should after- 
ward be exerted to keep the cavity clean and aseptic, if proper heal- 
ing after the discharge of the broken-down infiltrate is to be 
secured. 



DISEASES OF THE GUMS. 39 

CHAPTER XI. 
DISEASES OF THE GUMS. 

The gums are largely made up of fibrous tissue covered by 
mucous membrane. In their normal condition they are of a deli- 
cate pink color, and are dense and hard. They invest the +eeth 
closely, and are adherent at their cervical portion. They are not 
especially sensitive, and in the absence of the teeth most kinds of 
food may be crushed upon them without great discomfort. Any 
departure from this general appearance or state is a pathological 
condition that demands attention from the dentist or oral physi- 
cian. Local irritations, inflammations and hypertrophies, or 
hyperplastic conditions of the gum tissues are, however, too seldom 
recognized, or if noticed are not accorded proper treatment. That 
which should form a considerable proportion of the practice of 
every dentist is sadly neglected. 

Inflamed, irritable, turgid gingivae, loosened from their 
attachment to the teeth so that the point of an explorer can pene- 
trate some distance beneath their free margins without resistance, 
with degenerated, atonic, congested blood vessels that discharge 
their contents at the least irritation, are so common as to excite 
little comment, and the patient is dismissed without the proper 
professional advice or remedial attention. These same unfaithful 
practitioners perhaps bewail the multiplication of dentists, and 
insist that our schools should limit the launching of new graduates 
upon an already crowded profession, because there is not enough 
of practice for those already in, while themselves neglecting a large 
proportion of the field that should be covered. Properly to care 
for the disregarded conditions of the mouths of the people of this 
country would more than employ the time of all the dentists now 
existing. The proper remedy for a stream that overflows its banks 
is to widen and deepen its channel, instead of attempting to dry up 
its waters, and there are unoccupied fields within the province of 
dentistry not only as yet uncultivated but almost unexplored. 

Local irritation is the cause of most of the inflammations and 
hypertrophies of the gums that are so commonly met with. Usually 
this is due to lack of care oil the pari of the patient. Foreign mat- 
ter is deposited at the cervical portions of the teeth, and this by its 
excitant action stimulates the tissues to abnormal activity. The 



40 ORAL PATHOLOGY AND PRACTICE. 

consequence is an overgrowth, an hypertrophy or hyperplasia of 
tissue. This may be confined to a single tooth, or it may be more 
widely diffused and involve nearly or quite the whole of the denti- 
tion. The tumefaction will be especially pronounced in the gum 
covering the septum between the teeth, where the irritation is 
greatest. If there are carious cavities, not infrequently they will be 
completely filled with hyperplastic tissue, connected with the rest 
by a slender pedicle. The margins of the gums will be thick, 
everted, and of a deep red color, almost approaching a purple. 
There may be a breaking down of the tissue with pus formation, 
entirely distinct from that condition called pyorrhea. The mucous 
follicles of the gums are in a degenerative state, and their secretion 
no longer properly lubricates the tissues, but adds to the disturb- 
ance by its perverted character. 

These conditions arise as the effect of local irritation 
due to the presence of foreign substances, rough projecting 
fillings, or deposits about the necks of the teeth. Diagnosis 
is not difficult, for the very existence of the disturbance indicates 
the presence of exciting agents. The first curative measure to be 
adopted obviously is the removal of any local deposits or foreign 
substances. Nor is it sufficient to do this superficially. Wherever 
there is any undue amount of tissue or tumefaction, beneath it, 
perhaps at the very edge of the alveolar walls, will be found some- 
thing foreign. It is absolutely essential that the instrument used 
should penetrate to the very point of attachment, beneath the 
inflamed tissue, and to this end one that has a chisel edge, adapted 
to a pushing motion, will be most effectual, for anything thicker 
will not reach to the very extremity. It should not be forgotten 
that the most mischievous irritant matter is that which lies deepest, 
and nearest the point of actual attachment of the pericementum to 
the tooth. 

Minute spicules of calcific matter are those which 
cause the greatest disturbance. Whether these have their 
origin in the fluids of the mouth, or of the circulator}' system, 
whether they are salivary or sanguinary, local or constitutional, 
their operative treatment is the same. That such deposits of hard, 
sharp, segregated granules beneath the gums differ from the ordi- 
nary tartar or salivary calculus that is precipitated upon the supra- 
gingival portions of the teeth must be patent to everyone, but 



DISEASES OF THE GUMS. 41 

whether this divergence is due to its derivation, or merely to the 
manner and place of its deposit, we need not now inquire. Certain 
it is that its removal is more difficult than that of ordinary salivary 
calculus. It perhaps will not be detected without the exercise of 
considerable care, for it sometimes exists in minute spicules that 
would be invisible even if not covered by the inflamed gum. 

A solution of trichloracetic acid, of from twenty to fifty per 
cent, will greatly aid in the removal of these deposits. It may be 
carried on the edge of a sharp, wedge-shaped piece of orange wood 
that has been dipped in the solution. While the acid does not 
remove the deposits by dissolving them, it will loosen their attach- 
ment to the teeth, and soften them enough to facilitate their 
removal with the scaler. At the same time the remedy acts as a 
slight cauterant, inducing a slough of the superficial parts of the 
degenerative tissue, and reducing the inflammatory condition by 
its astringent and alterative action upon the distended, congested 
capillaries. A solution of lactic acid has been highly recommended 
for the same purpose. The patient should be directed to use fre- 
quent massage of the gums with the ball of the finger, and the per- 
sistent use of a soft tooth-brush should be insisted upon. The 
mouth should be gargled and the gums washed with a solution of 
twenty grains of chlorate of potash to the ounce of water, and if 
necessary a solution of chlorid of zinc may be prescribed for oral 
use. If there is a great deal of bleeding, tannic acid may be rubbed 
upon the gums with the finger. If, as is probable, an antiseptic 
wash is needed, a solution of boroglycerol in water, one part to 
ten, may be used as a wash or with the brush. It will not usually 
be wise to attempt the removal of the deposits from all the teeth 
at one time if many are affected. 

The medicinal treatment needs repeating at intervals of a few 
days until the condition is changed, and it is well at each of the 
visits to explore still further for irritating substances. An indica- 
tion of their existence and their locality will be found in the local 
persistence of the inflammation. Am red. irritable poinl of hyper- 
trophied gum will he found to cover the cause of irritation. 

Of the inflammations arising from loose or ragged teeth it is 
unnecessary to speak. The removal of the source of irritation 
will be sufficient. The gums beneath ill-fitting plates frequently 
become tumefied, and sometimes sloughing ensues. This is 



42 ORAL PATHOLOGY AND PRACTICE. 

especially the case with rubber plates, not because they generate 
any heat, but because they are non-conductors and the tissue 
beneath them is not subjected to the same variations of tempera- 
ture as the other and surrounding tissues. The condition may 
sometimes be found beneath metal plates that are not adapted to 
the mouth, if they are worn continuously, but there is not the 
same degenerative lack of tone in the blood vessels that is found 
beneath rubber dentures. The congestion is usually less intense, 
and sloughing is more infrequent. The cure for this condition will 
be found in the construction of a proper denture, and its inter- 
rupted use. No artificial plate should be allowed to remain in the 
mouth over night. The tissues should be given that opportunity 
for rest and the recovery of their normal tone. 



CHAPTER XII. 
STOMATITIS. 



The word is derived from the Greek "stoma," a mouth, and the 
termination "itis," inflammation, so that it implies an inflamma- 
tory condition of the tissues of the mouth. The term is a very 
broad one, and may be made to cover very diverse conditions. Its 
application, however, is usually restricted to the mucous mem- 
brane and the soft tissues in immediate relation with it. It is very 
common in infants among the lower classes of foreigners espe- 
cially, and is usually due to bad hygiene or unsanitary conditions. 
Especially is this the case with those that are artificially fed instead 
of being nursed by the mother. Either the food is of an improper 
character, or the nursing-bottle is not often enough scalded or 
boiled out to prevent the growth of fermentative organisms, and 
the milk used is thus infected. The rubber nipple and tube are 
often the source of irritation to the oral tissues. The rubber under 
the influence of light and heat rapidly commences decomposition, 
and thus becomes the means of poisoning the mouth. Or it may 
harbor destructive fungi, and these are especially irritating to the 
mucous membrane. 

Follicular Stomatitis, the simplest form, is an inflammation of the 
mouths of the mucous follicles. Tt is either accompanied by or will 
bring about degenerative changes of the mucosa itself, and this 



STOMATITIS. 43 

may add materially to the irritation. Perhaps but a portion of the 
surface may be affected, and the membrane presents a punctate 
appearance — flecked over with red points. With the increase of 
the inflammatory condition more of the follicles are involved, until 
the patches become confluent, and the whole surface is tumid and 
turgid. In this condition the tissues of the mouth look hot, dry, 
and red. The mouth becomes sensitive, and the child shrinks 
from its examination. There will, in the earlier stages, be an 
excessive slavering, or flow of watery saliva. There will be more 
or less of febrile disturbance, and the bowels will probably be 
irregular, a constipated condition predominating. During a later 
stage the secretions of the follicles become yet more depraved 
and no longer give the normal lubrication to the parts. The de- 
generation spreads to the connective tissue, the mouth becomes 
dry and parched, the blood vessels are congested and active nutri- 
tion is interrupted, the congestion reaches the point of stasis, or 
stoppage of the circulation, and sloughing commences. 

Acute Stomatitis may be induced by improper feeding, aside 
from unsanitary conditions. The infant that is fed with a food 
that it cannot digest will be poorly nourished, and all kinds of 
degenerations may be established. The irritative condition of the 
digestive tract may produce diarrhea and gastric disturbances 
which by mere continuity of tissue may extend to the oral mucous 
membrane, and an ulcerative stomatitis may be established as the 
result of the atonic, innutritive state, and the spread of the inflam- 
mation from the irritated digestive tract. 

Ulcerative Stomatitis is merely an advanced stage of the first 
condition. The mucous follicles become so degenerated that their 
functions quite cease, and cracks and fissures open in the unlubri- 
cated tissues. All the preceding symptoms are aggravated. The 
child cannot without great difficulty take its food, and what is 
ingested affords little nutriment, because of the gastric disturb- 
ances that are always present. There is a constant swallowing of 
offensive matter from the mouth, with a wasting diarrhea <>r dysen- 
tery. 

About tin's time the submucous tissue will perhaps become 
thickened and indurated in spots. Sometimes there will lie ptyal- 
ism, with a great flow of watery saliva succeeding the dried condi- 
tion of the oral cavity. The submaxillary gland may become ten- 
der and tumid. Small vesicles may appear iii tin' mouth, seem- 



44 ORAL PATHOLOGY AND PRACTICE. 

ingly filled with a watery serum. These burst and form an ulcer, 
with a dirty-white slough. The child becomes greatly emaciated, 
and there is excessive swelling of the oral tissues. The breath 
becomes very offensive, and the ulcers show a considerable slough- 
ing. Unless speedy relief is obtained, the child will soon succumb 
through lack of nutrition, as well as to the infectious products of 
the septic condition. 

Aphthous Stomatitis is a form that may attack people of almost 
any age, and is characterized by some special appearances. Small 
round or oval ulcers appear upon the reddened mucous membrane 
of the lips, cheeks, tongue, or gums. They are from one to three 
lines in diameter, very little depressed, with a yellowing or white 
floor, and a red, narrow, perhaps slightly indurated, border. 
Sometimes two or more of them become confluent, thus forming 
an irregular, large ulcer. When these heal they leave no cicatrix. 

Usually there is an increased flow of saliva accompanying 
them, the mouth is hot and feverish and the tongue heavily coated. 
Sometimes the saliva excoriates the skin and the lips are thus kept 
constantly sore. 

Thrush is a form of stomatitis occurring in children and depend- 
ent upon the growth of a parasitic fungus. This consists of long, 
jointed threads, the Oidium albicans, which seems to belong to the 
family of the molds. Thrush appears to be contagious. On look- 
ing into the mouth of young infants a layer of thin white mem- 
brane may perhaps be seen covering the palatal arch and appearing 
as white spots upon the tongue, while the mucous membrane about 
or at the borders of this coating seems to be in a healthy condition. 

Thrush in children is apt to be a sequela of chronic diarrhea, 
prolonged starvation, exhausting fevers, or any severe and debili- 
tating illness. It is indicative of and usually accompanies a low, 
atonic condition, and its cure will depend more upon feeding than 
medicines, first allaying any gastric or intestinal irritation. 

Noma, Gangrenous Stomatitis, or Cancrum Oris, is a kind of 
ulcerative stomatitis, but as the term is usually employed it implies 
a specially vicious degenerative condition, due to infection by a peculiar 
bacillus. 

The preceding remarks are more especially applicable to in- 
fantile stomatitis. The same or analogous conditions may be 
induced in adults by like causes. Anemic and poorly nourished 



TREATMENT OF STOMATITIS. 45 

persons are especially liable to inflammations of the oral tissues. 
The lips are dry and parched, and superficial fissures and cracks in 
the mucous membrane appear. In a less degree this will be ob- 
servable upon the tongue, the buccal surfaces, and in the vault of 
the mouth. This may continue for some time, until finally, with the 
progression of a general febrile state, a more active stomatitis is 
developed that may result in a local breaking down or ulceration. 

Neglect of the teeth and the mouth tissues is a fruitful source 
of stomatitis in adults. Food is left to ferment and putrefy, and 
the products of this action will be exceedingly irritative to the 
soft tissues, as well as destructive to the hard. There will always 
be gingivitis present in the mouths of those who do not give 
proper attention to the removal of foreign substances from about 
the teeth, and this, by continuity of tissue, may spread all over the 
mouth. Usually the action of the saliva upon the portions freely 
washed by it is sufficient to keep them clean and normal. But 
between and about the teeth, where food remains for an indefinite 
time, in the absence of proper care the gums are always irritated 
and more or less congested, and this may spread to adjoining 
tissue, with the result of an acute stomatitis in atonic conditions. 



CHAPTER XIII. 

TREATMENT OF STOMATITIS. 

In infantile affections the very, first measures to be adopted 
necessarily imply an inquiry into the food and feeding. If the 
child is artificially fed, the nursing-bottle should be carefully 
inspected, and the food that is given must be scrutinized. If there 
is anything unsanitary about either, it must be at once corrected. 
Tin- rubber nipple and tube must be sterilized, or, what is better, 
discarded and substituted by a new one that has been made thor- 
oughly aseptic. If the child is poorly nourished through improper 
or insufficient food, that must be remedied, and plenty of nutritious 
matter that can be readily digested and assimilated should be 
given. If there arc diarrheas or other wasting disorders, which 
will too often be the case, they must at once be attended to; it 
will be impossible to build up a patient while any process of waste 
is going on. All unhygienic surroundings must be remedied, and 



46 ORAL PATHOLOGY AND PRACTICE. 

the patient should be given plenty of light and air, and proper 
exercise. In short, beneficent Mother Nature, upon whom we 
must finally rely for a cure, must be afforded every opportunity. 
Functional activity must be promoted, and all obstacles removed. 

After securing perfect sanitation the local treatment will be 
mainly depurative and stimulative. If a cathartic is indicated, 
two drams of castor oil may be administered. For the local 
irritation, a mouth-wash consisting of a solution of five to ten 
grains of chlorate of potash to the ounce of water may be used as 
a gargle. If the child is too young to use this itself, a swab may 
be made by tying soft linen to a stick of proper dimensions, and 
this may be used to apply the solution, employing a proper degree 
of friction. If the mouth is sore, it may be applied with a soft 
brush. The mouth may be occasionally washed out with the 
following preparation, especially after eating: 

R — Borax, 30 grains; - J 

Sodium bicarbonate, 1 dram; 

Distilled water, 4 ounces. 

Or the following may be substituted in its place : 
K — Boric acid, 

Potassium chlorate, of each 15 grains; 
Lemon juice, jounce; 

Glycerol, 6 drams. 

If an antiseptic is needed, a solution of listerine, one part in 
ten parts of water, may be used in the same way, or it may be 
administered internally when diluted with simple syrup. Or the 
following may be prescribed: 

R — Listerine (Lambert's), 2 ounces; 

Glycerol, 1 dram; 

Water, to make 4 ounces. 

Sig. — A teaspoonful after nursing or feeding. 

If there are cracks in the tongue or fissures in the cheeks, a 
solution of borax and honey may be used locally, made by adding 
one dram of borax to each ounce of clarified honey. 

If there are deep erosions of the mucous membrane, or ulcera- 
tive surfaces, it may be necessary to cauterize them, either with 
silver nitrate, pure carbolic acid, or chromic acid crystals. The 
last named are preferable in instances in which they can be con- 
veniently used. The cauterized places should be subsequently 
dressed with a solution of calendula. 



TREATMENT OF STOMATITIS. 47 

The treatment of follicular, or ulcerative, stomatitis in 
adults does not materially differ from that in infants, 
except that more active measures may be used. The reme- 
dies may be proportionally increased in strength, and personal 
care insisted upon. The teeth should be thoroughly cleaned, and 
all broken or sharp edges removed. A soft tooth-brush should 
be employed after every meal, and with it should be prescribed 
some antiseptic wash. A two per cent, solution of zinc chlorid 
may be used as a gargle. At night a spoonful of Phillips' milk of 
magnesia should be taken into the mouth and rinsed about all 
the teeth, to be left upon them until the morning. Enough of 
good nourishing food should be given, and the patient should have 
plenty of pure air and sunshine. 

There is a form of ulcer that is the result of the careless appli- 
cation of arsenous acid in the devitalization of teeth, which may 
be referred to in this connection. Arsenic is a corrosive poison. 
It produces its characteristic effects in destroying the pulps of 
teeth, not through congestion and the production of consequent 
stasis at the apical foramen, because it will promptly kill the pulp 
of a partially developed tooth in which the root is entirely open, 
no foraminal constriction having yet been formed, and in which 
strangulation is therefore impossible. When arsenous acid is 
insecurely sealed up in the cavity of a tooth, such a defective agent 
as a solution of gum sandarac being employed for that purpose, 
it may come in contact with the buccal tissue and devitalize that, 
gradually eating its way in until a considerable slough is pro- 
duced. 

When this is the case, the ulcer should be thoroughly satu- 
rated with dialyzed iron, to limit the action of the arsenic. It 
should then be dressed with a solution of calendula, and kept clean 
and aseptic until it has healed. Should the corrosive effects be 
manifest between the teeth, and reach to the alveolar bone, it will 
probably induce an osteitis that may end in caries or necrosis. 
When this is the case, the affected bone should be promptly burred 
away before using tin- dialyzed iron. 

In Gangrene, or Noma, or Cancrum Oris, thorough cauteriza- 
tion or removal of the affected tissue will probably be necessary, 
and the strictest antiseptic precautions must be employed. For the 
-incral symptoms constitutional treatmenl must betaken. Tonics 
should be employed, with fresh air and a sufficient amount of 



48 ORAL PATHOLOGY AND PRACTICE. 

exercise. Every possible effort should be made to promote nutri- 
tion, and especially that of the locally affected tissues. In fact, 
when stomatitis reaches the point of deep ulceration or extensive 
breaking down of tissue, it is such a grave condition that general 
constitutional treatment should not be delayed. 

Sometimes the pulps of teeth assume a gangrenous condition. 
When this is the case, there is great danger that septicemia and 
pyemia may be the consequence. Miller details a number of cases 
within the sphere of his own observation, in which death within 
a very few days has been the result of the gangrenous infection 
of a tooth pulp. When the symptoms of general septic poisoning 
are manifest, no time should be lost in the institution of the proper 
general remedial measures, the consideration of which is beyond 
the scope of this work. 

In cases of thrush in infants that are badly or insufficiently 
nourished, there is usually more or less of gastric or intestinal irri- 
tation in connection with the markedly atonic condition. This will 
probably require the administration of such correctives as rhubarb 
and soda, lime-water, and vegetable bitters. When the aphthae 
occur in older persons they are often spoken of as "canker spots," 
or "canker sore mouth." The usual treatment is roughly to cau- 
terize the spots, and dress them with a solution of calendula. If 
an active cauterant is not desirable, as in children, the aphthous 
patches may be repeatedly touched with the following solution: 

R — Sodium salicylate, 1 dram; 

Distilled water. 6 drams. 

Or in place of the preceding this may be used: 

II — Borax, 45 grains; 

Sodium salicylate, 75 " 

Tinct. myrrh, 1 dram; 

Simple syrup, 
Distilled water, of each J / 2 ounce. 

If the aphthae exist in considerable numbers, they may demand 
the use of antiseptic mouth-washes. If they are the consequence 
of a general anemic condition, tonics and alteratives are of course 
indicated. While they are peculiarly uncomfortable, the aphthae 
have no serious pathological signification, except as they are in- 
dicative of an atonic condition. 



PHARYNGITIS AND TONSILLITIS. 49 

CHAPTER XIV. 

PHARYNGITIS AND TONSILLITIS. 

There are many pathological conditions of the oral cavity r 
and of the immediately connected tissues and organs, that should 
fall within the province of the oral physician or dentist, but which 
are usually relegated to the general medical man. When the time 
shall come in which no man will be allowed to enter upon oral 
practice who is not thoroughly qualified to treat all oral condi- 
tions, dentistry will occupy a very different place in general esti- 
mation from that of to-day, and there will be plenty of room for 
all the competent* men whom it will be possible for the colleges 
to turn out. At present, diseases of the pharynx are usually sup- 
posed to be beyond the scope of the dental practitioner. And yet 
there are no specialists to whom such affections should so naturally 
fall, and there are none who have such opportunities for observa- 
tion and detection of pharyngeal lesions. It but needs that these 
shall be brought within the limits of his practice, and that he shall 
properly qualify himself for their treatment, to bring great benefits 
to both the dentist and the people. 

The pharynx is a pouch, largely aponeurotic, which is divided 
into two parts by the soft palate. It has seven openings — that of the 
mouth, the two Eustachian tubes, the larynx, the esophagus, and the two 
nares. Its diseases are mainly those of the mucous membrane. There 
is no more common affection than angina simplex, a common 
sore throat, the effect of that inflammation that we call a cold. 
It is accompanied with irritation, huskiness, and pain in swallow- 
ing, and its remedy is in cleansing, a'ntiseptic, and anodyne gar- 
gles, a solution of chlorate of potash being that most commonly 
used. 

A large proportion of pharyngeal affections are the direct 
results of lesions within the oral cavity, brought about by con- 
tinuity of tissue. There are certain diseases of the tonsillar glands 
that are not included in this origin, and there are inflammations 
dependenl upon laryngeal lesions as well, but a considerable 
number of the affections are due to oral trouble. Complications 
arising from impactions of the wisdom tooth and its investments 
are one of the most frequenl of these. Owing to a lack of develop- 
ment, especially in the length of the body of the lower jaw, fre- 

5 



50 ORAL PATHOLOGY AND PRACTICE. 

quently there is not sufficient room for the eruption of the tooth, 
and it becomes imbedded in the tissues, a constant source of irri- 
tation. Sometimes the inflammation about it is so intense as to 
prevent the opening and closing of the mouth. At times there is 
a breaking down of tissue, and suppuration ensues. From the 
initial point of the lesion, dark-red lines extending down into the 
pharynx may be observed, and there is a distinct and sometimes 
an acute inflammation of the pillars of the fauces, with great dis- 
comfort, or even acute pain. 

In cases of cleft palate there are almost always com- 
plications involving the anterior and posterior nares. 
When these are presented to the dentist he usually proceeds to 
the construction of some prosthetic apparatus for the purpose of 
supplying the loss, without any preliminary attention to the soft 
tissues themselves. In all cases of complete or incomplete cleft, 
the pharyngeal walls, as well as those of the nasal cavity, are in an 
irritable, inflamed, hyperemic state. This could not well be other- 
wise, because they are not protected by the usual palate, and are 
subjected to the irritating action of food and drink every time it 
is taken. Xot infrequently there are excoriations and abrasions 
of the edges of the palatal cleft, with degenerative conditions of 
the mucous membrane of the posterior nares that require active 
treatment. The oral physician or surgeon seldom notices them, 
because they do not form a part of the regular practice to which he 
confines himself. 

Inflammations of the pharyngeal tissues, arising from 
the changes in the neural currents commonly called 
"taking cold," are quite common. If the tongue is depressed 
by placing upon it a broad' spatula, the whole pharyngeal cavity 
will appear of a bright-red color, with the parts considerably 
swollen. The uvula will appear lengthened and pendulous. There 
will be a dryness in the fauces, with huskiness of the voice and con- 
siderable pain on swallowing. The Eustachian tube will appar- 
ently be closed, and the hearing will be materially affected. 

These simple follicular inflammations usually result in a ready 
resolution, but their time may be cut short by proper remedial 
measures. If there are no abscesses or deep erosions, hot pedi- 
luvia should be resorted to, with saline cathartics and diaphoretics. 
The latter class of remedies is of importance, and a general 
diaphoresis will usually greatly hasten a cure. Twenty or thirtv 



PHARYNGITIS AND TONSILLITIS. 5 1 

grains of potassium bromid, with five drops of tinct. veratrum 
viride, may be taken in a small glass of water, when the patient 
should go to bed and cover up warm. A gargle of chlorate of 
potash may be used if the attack is not very acute. If there is any 
infection, an antiseptic gargle, such as a teaspoonful of phenol 
sodique in a glass of water, or five grains of chlorid of zinc to the 
ounce of water, may be employed. If there are excoriated surfaces 
they may be touched with a cauterant. 

Tonsillitis. 

The tonsils are sometimes severely attacked by parenchyma- 
tous inflammation. Where this is comparatively slight, a careful 
examination may be necessary to distinguish it from some forms 
of pharyngeal inflammation. But there are instances in which 
the tonsils become so greatly inflamed as to prevent swallowing 
and to impede breathing, and active scarification becomes a neces- 
sity. Usually, however, the swelling may be allayed by a phenol- 
sodique gargle, or one of which sodium bicarbonate forms the 
base. If there is much pain the tonsils may be painted over with 
a cocain solution. If suppuration ensues despite all measures to 
prevent it, the pus should be voided as soon as possible, and the 
usual antiseptic treatment follow it. 

In tonsillitis of an especially acute character Prof. F. J. S. 
Gorgas recommends the following prescription: 

IJ — Acidi gallici, gr. xl; 

Liq. socke chlorinatse, oij; 

Glycerol, oij ; 

Aquae dest, oviij. M. 

Sig. — To be used as an antiseptic and astringent gargle. 

It should not be forgotten that the tonsils are frequently 
marked with deep sulci and furrows, especially if they have been 
the seat of repeated attacks of septic inflammations. These de- 
pressions form favorable harbors for the proliferation of different 
forms of pathogenic and saprogenic bacteria. When this condi- 
tion is observed, great care should be exercised to keep the exter- 
nal surfaces of the glands in an aseptic condition, lest the sup- 
purative condition commonly called quinsy become chronic. 



52 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XV. 
DISEASES OF THE TONGUE. 

Properly read, the appearance and superficial condition of the 
tongue is an index to most gastric and to many other general dis- 
turbances. In health it is of a delicate whitish pink color, smooth 
and moist. Any departure from this appearance indicates a patho- 
logical condition, not necessarily of the organ itself, but of others 
whose disturbed state is reflected upon the tongue, and especially 
of functional aberrations which interfere with digestion. It may 
be covered with the so-called "fur," which is a coating made up of 
the epithelial scales that have not been thrown off, of certain gran- 
ular matters, of inspissated or degenerate mucus, and of detritus. 
The investment of the tongue with this coating always commences 
at its base, and gradually invades the dorsum until the tip is 
reached. The clearing up of the tongue during convalescence is 
from the tip and borders toward the base, so that the progress or 
recession of this coating will furnish an index to the condition of 
the patient from day to day. A furred tongue is a symptom of a 
defective circulation. 

In addition there are certain well-established appearances that 
are indicative of special pathological conditions: 

Extreme humidity — Indicates atony, with anemia. 

Extreme dryness — Nervous irritation or weakness. 

Elabbincss or tremiilousness — Extreme weakness. 

A grayish white color after eating — Normal digestion. 

A yellowish white — Acidity, with biliary irritation. 

Very white, thick coating ("flannel mouth") — Intense venous 
congestion. 

A delicate pinkish red — Digestion completed. 

A deeper hue of red — Arterial congestion; irritation. 

Very deep dark red — Active inflammation. 

Bright red, raze or glazed — Approaching fatal exhaustion. 

Brownish red, with thick dry coating — Prostration; danger. 

Black, not a deep hue — Blood poisoning; pyemia. 

Bluish tinge — Cyanosis; lack of oxygen. 

The indications upon the tongue of a dangerous condition are 
tremulous action, extreme dryness, blueness, a very red, shining or 
glazed aspect, and heavy furring of a dark or black hue. . 



DISEASES OF THE TONGUE. 53 

In considering the tongue as a diagnostic organ, however, its 
indications are not to be depended upon alone. Its appearance 
should always be studied in connection with other symptoms, 
which may dominate the decision. It is to be considered only as 
an important auxiliary in arriving at a conclusion. 

Of itself the tongue is subject to many pathological conditions. 
It is manifestly impossible within the limits of a work like this to 
consider all these, or to do more than to note those degenerations 
that are of greatest interest to the oral specialist. The remainder 
more especially belong to the general practitioner. 

Glossitis, inflammation of the tongue itself, whether sympa- 
thetic or idiopathic, belongs to the first-named class. When it is 
the result of some injury or traumatism, it especially appeals to 
the oral practitioner. The tongue may be wounded by the 
careless use of instruments, and great inflammation may be the 
result. An excavator or bur that has been used in a gangrenous 
tooth pulp may wound the tongue and cause alarming symptoms 
as the result of the septic infection; a very short time may suffice 
to cause such an intense infiltration that suffocation will appear 
imminent. The swollen tongue may fill the mouth to the utmost 
point of distention. The general system may sympathize and the 
pulse grow rapid, a feverish condition supervene, and a state ensue 
that causes the most intense anxiety, from the alarming symptoms 
presented. 

An acute glossitis will usually, however, end in complete reso- 
lution without such startling symptoms. It may be necessary, 
and it is usually advisable, to administer an active cathartic, and 
to promote diaphoresis by means of potassium bromid, or spirits 
of Mindererus, with warm drinks. If there is a septic wound it 
should be opened to its bottom, to permit the escape of any infec- 
tious products. If the swelling assumes dangerous proportions, 
no time should he lost in making deep incisions into the body of 
the tongue. These should not he long or continuous, hut merely 
deep punctures with a bistoury, and as many as may seem indi- 
cated. 

Syphilitic ulcers, swellings, cracks and fissures, indurations, 
hypertrophies, etc.. are comparatively common, but their consid- 
eration need not engross our attention at this time. 

Injuries from the teeth are not uncommon, and sometimes 



54 ORAL PATHOLOGY AND PRACTICE. 

undoubtedly result in degenerative conditions of the gravest char- 
acter. The tongue is continuously irritated by the sharp edge of 
a decayed or broken tooth, and a thickening of the tissue, with 
induration, follows, even though the mucous membrane is not 
broken. The irritation being kept up, the scirrhosis increases 
until there comes a time when it breaks down in the center, an 
indurated border yet remaining. This may present the appear- 
ance of syphilitic gummata, and may have consequences almost as 
disastrous. No dentist should leave in the mouth any such tooth, 
if it falls under his observation, for it may result in a serious com- 
plication. When such a thickening is found all source of irrita- 
tion should be removed, and if it does not disappear it may be 
necessary to remove it by surgical interference, lest it assume a 
malignant form. 

If an eroded ulcer is the result of such a sharp tooth, 
and if upon removal of the cause it presents an indolent 
appearance, a chlorid of zinc wash of not more than ten 
grains to the ounce of water may be used, or one made by 
the addition of a little compound tincture of capsicum in 
water. Violent, or drastic, or surgical measures should not, 
however, be lightly resorted to. Plenty of time should be given 
for nature to bring about a cure, and general measures, like tonics 
and alteratives, should be resorted to, lest too active local inter- 
ference bring about the very state that it is desired to avoid. 



CHAPTER XVI. 

DISEASES OF DENTITION: GENERAL CONSIDERATIONS. 

The fact that a considerable portion of the human family die 
before they have reached the period at which the last of the 
deciduous teeth shall have been erupted, and that the period of 
greatest mortality is that during which the teeth usually make 
their appearance, has led to the popular belief that the one is 
necessarily dependent upon the other; that dentition is the cause 
of the high death-rate among children, instead of being coinci- 
dental. That it is possible for a retarded or disturbed dental 
development to induce very serious derangement is indisputable, 
but that it is a principal factor in inducing the great number of 



DISEASES OF DENTITION. 55 

deaths that occur in children can scarcely be maintained. There 
are many cogent reasons for the contrary belief, while there is 
nothing, save the mere fact of coincidence, to sustain the theory 
too commonly accepted without inquiry or consideration. 

There is a lack of comprehension as to the true character of 
the diseases that cause this high death-rate in children. Digestive 
derangements are not the main factor, and yet, if we except 
nervous disorders, these are the only ones that can with propriety 
be urged as the possible result of disturbances in dentition. 
Statistical summaries nowhere give the cutting of teeth as a cause 
of death. The following tables will be found very instructive in 
the study of infant mortality. They are derived from reliable 
sources, and are presented in the hope that they will afford 
assistance to those Avho desire to investigate for themselves, 
rather than to obtain all their information at second-hand. The 
traditionary instruction given in medical schools is that the teeth 
are a very important factor in producing the high death-rate of 
infancy. It is the imperative duty of dentists to examine the 
facts, and to inquire if this hypothesis is not founded in error, 
due to insufficient study and knowledge, like that other assump- 
tion of certain medical authorities, that pulpless teeth are the 
principal source of disease of the maxillary sinus, and a continual 
menace to health. 

Percentage of probability that a child born, alive will die 
of different diseases. 

Phthisis 1 144 Diphtheria 0049 

Diarrhea and dysentery 0343 Brain diseases 1218 

Typhoid 0381 Lung diseases 2640 

Scarlet fever 0300 Stomach and liver diseases. . . .0524 

Whooping-cough 0151 Heart disease and dropsy 0766 

sles 0128 Kidney diseases 0149 

This shows that diseases of the lungs, which include phthisis, 
arc the most fatal, and that more than twice as many people die 
of brain disease as of stomach troubles. 

Mean age at death of people dying from various diseases. 

Mules. Females. Mian. 

All causes 28.2 30.8 29.5 

Whooping-cough 1.7 1.8 1.75 

Measles 2.5 2.8 2.7 

! !> 3-i 3-2 3-15 



Females. 


Mean. 


8.1 


7-9 


5-6 


5-4 


10.6 


11.9 


14.9 


134 


32.4 


31-4 


32.8 


34-3 


41.4 


40.6 


48.8 


45-8 


57-2 


58.6 



56 ORAL PATHOLOGY AND PRACTICE. 

Males. 

Diphtheria y.y 

Scarlet fever 5.2 

Smallpox 13.2 

Diarrhea 1 1 .8 

Cholera 30.4 

Erysipelas 35.7 

Rheumatism 39.8 

Influenza 42.8 

Carbuncle 59.2 

This table indicates that the diarrheas are not confined to 
childhood, but that they are also destructive in middle life. 

Average infant mortality in different countries. Percentage of the 
population dying under five years of age. 

Norway 17 France .. 31 

Ireland 17 Prussia . 32 

Denmark 20 Holland ^ 

Scotland 20 Austria 36 

Sweden 20 Spain 36 

England 26 Russia 38 

Belgium 27 Italy 39 

This table shows that in the warmer and more thickly popu- 
lated countries infant mortality is greater than in those lying 
farther north, and which have fewer people to the square mile. 
In this connection the following table will be of interest: 

Death-rate per 1000 under increase of the population to the square mile. 

Population to sq. mile 166 186 379 1,718 4,449 12,357 65,823 

Death-rate at all ages 16.94 19.18 21.90 24.81 28.02 32.96 38.67 

Under 5 years -37-8o 47.53 63.06 82.10 94.04 11 1.90 139.52 

This table shows that with an increase in population the 
death-rate in young children is very much greater than in adults. 

Number of births in the several months of the year in different 

countries, 100 being considered the general 

normal az^erage. 

France. Germany. Spain. Italy. 

January 105 103 1 14 107 

February in 105 108 114 

March 109 103 112 no 



DISEASES OF DENTITION. 57 

France. Germany. Spain. Italy. 

April 106 ioo 102 106 

May 99 97 100 95 

June 95 95 89 89 

July 96 96 88 91 

August 96 98 91 93 

September 97 106 98 100 

October 95 100 100 98 

November 97 100 97 98 

December 95 99 100 97 

It is only in the older countries that these statistics, which 
are compiled from government records, are kept. In America 
the census reports have not until lately been thus complete. The 
lesson to be learned from these presentations is, that while birth- 
rates do not widely, differ, the death-rate is subject to many contin- 
gencies. The diseases of which children mostly die are not those 
which could be materially influenced by the cutting of teeth. Xo 
one will claim that dentition could be active in increasing the 
number of deaths from contagious disorders, like measles, scarlet 
fever, and whooping-cough. As has been already stated, nowhere 
is the cutting of teeth statistically given as the direct cause of 
mortality. Although it may in some instances induce death 
through some other complication, its influence is too insignificant 
to be included as a separate cause. 

All these facts should lead us to give close scrutiny to the 
assertions of those who claim that any considerable number of 
infants die from cutting teeth. A distinction should be clearly 
drawn between the so-called diseases of dentition, which may be 
digestive disturbances, and those that are actually produced by 
mal-development of the teeth, whose pathological history is quite 
different. The former class of derangements may properly 
belong to the general practitioner, while the attention of the oral 
pathologist should be more particularly directed to the latter. But 
as it is essential that both should be comprehended to make a clear 
diagnosis, each must in turn be considered, and they will for con- 
venience In- divided into the "so-called" and the "true" disturb- 
ances of dentition. 



58 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XVII. 
THE SO-CALLED DISEASES OF DENTITION. 

Those which we may denominate imputed diseases of dentition 
are the diarrheas, dysenteries, and fevers of infancy, which are 
true digestive disorders, and instead of having their etiology in 
the advancing teeth, arise from improper feeding during the period 
of most active development. All growth, whether in the vegetable 
or animal kingdom, is by alternate periods of activity and repose. 
In plants, winter is the season of rest and of the gathering of 
forces for the season of advancement. With the spring comes 
the period of growth, when the organism assumes an extraor- 
dinary energy. The leaves are put forth, and each twig shoots 
out with an amazing activity. The whole growth of a year is 
then made within a few weeks. But the tissue so developed is 
soft and succulent, without the woody structure that gives it 
strength and consistency. The summer, when increase and exten- 
sion have ceased, is devoted to the maturing and consolidation 
of the newly formed material, while in autumn all the energies 
of the plant are employed in perfecting the fruit or seed by which 
the preservation of the species is insured. 

The growth of the plant is analogous to that of the 
animal. Vegetable physiology does not in essence differ 
from that of the sentient being. The latter has also its periods 
of increase, of active expansion, and those devoted to the matur- 
ing and perfecting of that already formed. Many people have 
observed that children, after a period of seeming suspension of 
development, will within a few months add an inch or more to 
their stature. This is succeeded by another term of rest, when 
the tissues pass through a process of maturing. It is well known 
that during these terms of rapid growth young persons are more 
liable to injuries and illnesses of different kinds than they are 
either before or after them. It should not be forgotten that the 
teeth, like the other organs of the body, have their distinct eras, 
and that they develop with the rest of the body, and not inde- 
pendently of it. When the child is cutting its teeth, at the same 
time it is practically getting a new stomach and new digestive 
organs. Local causes aside, if the muscles do not develop, the 



THE SO-CALLED DISEASES OF DENTITION. 59 

jaw and teeth will not grow, for all are dependent upon the same 
digestion and assimilation of food. 

In the newborn infant none of the tissues are suffi- 
ciently developed to perform independent function. The 
muscles of the legs will not support its weight, and those of the 
arm are not sufficiently advanced to give it controlled action. 
The nutritive apparatus is as yet so imperfectly organized that 
it cannot fully digest food, and the child must be given pabulum 
that is already partly prepared for assimilation. It finds this in 
the greatest perfection in the milk of the mother, in which all the 
elements necessary to growth are held in solution in a conditioti 
exactly adapted to the state of development of the child. At 
birth this milk is less highly organized than it will be six months 
later. When the physician seeks for a wet-nurse for a newly born 
infant, he does not choose one whose child was born months 
previously, because her milk would be of such a character that 
the weak organs of the young babe could not finish, its digestion. 
The milk of one who has been a mother for two months would 
be too highly organized for the babe of a week. 

Xature has made all provision for the regular development 
of the child, and as its digestive organs become better developed 
the milk of the mother changes accordingly, until by regular 
progression, through successive advancing periods of growth, the 
various organs are sufficiently perfected for independent existence, 
and food that is partially digested is no longer a necessity for 
healthy functional action. This will only, in normal conditions, 
occur when the other organs are as far advanced as the digestive 
tract. The muscular system will have enough strength to enable 
the- child to perform necessary motion. The brain and intelli- 
gence- will be adequate to the proper selection of its food, while 
the teeth will be in a sufficiently advanced state to prepare the 
pabulum that is proper for its condition. As after this the body 
gradually develops, so that more highly organized food becomes 
a necessity, additional teeth arc given, the small ones of childhood 
are succeeded by those larger and stronger, until with the period 
of full puberty the dentition is completed simultaneously with the 
perfection of the other organs. 

Unless the regular graduation of food keeps pace with the 
evolution and progressive growth of the organs, all the processes 
of nature are deranged, function is interfered with, and disease is 



60 ORAL PATHOLOGY AND PRACTICE. 

the result. If the young child, with its digestive apparatus but 
little developed, is given food too highly organized, indigestion, 
with its consequent vomitings, diarrheas, and febrile disturbance, 
will be the result, and it is here that the "so-called" diseases of 
dentition have their origin. With the advent of the deciduous 
incisors, the muscular system is sufficiently advanced to allow the 
child to sit erect, and in the average family it is taken to the 
table at meal-time. The injudicious or ignorant mother places in 
its mouth some soft food, fit only for adults. The instinct of the 
child teaches it to reject the offered dainty. The sense of taste 
has not yet been wholly developed, nor will it be normally until 
the organs are sufficiently advanced for full digestion, and the 
morsel is ejected with a wry face. But the mother persists, and 
after a time it is swallowed. Perhaps a morbid, abnormal appetite 
is stimulated, much as later in life one for whiskey or tobacco or 
opium is acquired. 

The bolus having been swallowed, it must lie in the ele- 
mentary stomach as undigested as if it were leather or rubber. 
It is perhaps regurgitated, and thus expelled from the system. 
If the bad feeding is persisted in, this means of rejection is soon 
exhausted, and the foreign matter remains in the stomach, a 
continual irritant, until it 4 s violently passed through the pyloric 
opening and into the tender duodenum. Thence, by its irritating 
action as a foreign substance, it induces the violent peristaltic 
movements which, when kept up by the successive irruptions of 
the irritant, become a pronounced diarrhea, possibly to degen- 
erate into a dysenteric condition, with final death. 

And this, because it occurs about the period when the 
teeth are erupting, is ascribed to dentition. As well might 
puberty in the male be imputed to the growth of the whiskers, 
because they begin to appear at about this time. It is essential 
that the oral pathologist should have correct views upon this 
subject, and hence some time must be devoted to its consideration. 
There are a number of cogent reasons why the prevailing belief 
among physicians that diarrheas and other digestive disturbances 
are due to advancing teeth is erroneous. 

In the first place, their connection is remote, while that 
between the diarrheas and improper feeding is so close that 
the probabilities are greatly in favor of it as the cause, even 
on other than physiological grounds. 



THE SO-CALLED DISEASES OF DENTITION. 6l 

The growth of the teeth is as much a physiological process 
as is that of the hair or nails. Their development commences 
some time before birth, and continues for a long time after it. 
The mere erupting of the organs is but an incidental step in the 
process, and by no means its most significant or important one. 
Why should the growth of the teeth not induce disturbances of 
nutrition before birth, if it does after? 

The so-called diseases of dentition are confined to a 
comparatively small portion of the year, and that is pre- 
cisely the period when a change in the food of infants is 
most liable to be made in the average family, while denti- 
tion goes on all the year alike. There are as many teeth cut 
in January as in July, but the so-called diseases of dentition 
are as a hundred to one. This is abundantly demonstrated by 
the accompanying diagrams (see pages 62 and 63), which represent 
the mortality of the city of Buffalo for three years. What is true 
of that city is true of all others, except as the tables for the different 
months may be a little modified by latitude. 

From November to May, in the northern temperate zone, 
tlic death-rate of children from diarrheas and other digestive 
disturbances is about the same with each month. With the latter 
month it begins to rise, shoots upward with an amazing increase 
during June, and reaches its highest point in July. In August 
it falls slightly, rises a trifle in September, and then falls as 
rapidly during that month and October as it rose in June and 
July, again reaching the low point in November, where it remains 
until the succeeding May. This is more or less true of all cities. 
Statistics show that the rule is general, but it is especially appli- 
cable to the poorer people, and the diarrheas and dysenteries are 
mosl fatal in the wards and districts in which they chiefly live. 

The diet of the average workingman's family is necessarily 
restricted in its character during the winter. In April may be 
seen by the wayside, and in the yards and in fields, his wife and 
children gathering the early herbs, dandelion, plantain, and others, 
to boil for greens. These form a welcome change of diet and are 
appetizing. What is grateful to their own palates, they argue, must 
be good for the baby, and it is fed From the family dish. I )igestive 
disturbances commence, and they are intensified by giving it other 
early vegetables, and perhaps stale Fruit. There is a period of 
incubation of the disease; it gradually increases in intensity, and 



62 



ORAL PATHOLOGY AND PRACTICE. 



Table I. 

Death-rate, from All Causes, of Children under Three Years, in the 
City of Buff ah, for the Years 1888, 1889, and 1890. 

(The.interrupted line indicates the average temperature, the continuous line denoting the rise 
and fall of the death-rate.) 



AV. TEMP. 


JAN. 


FEB. 


MAR. 


APR. 


MAY 


JUNE 


JUl.V 


ALT.. 


SEPT. 


OCT. 


sov. 


di:c. 


DEATHS 


72° 


























3/8 


70° 














/f 


>° 










364 


68° 














^ v 












350 


66° 












/ 
/ 




\ 
\ 










330 


64° 












,*» 


'327 


V* 


,a 








322 


62 












1 


h 


a \ 


, 








308 


60 ° 












/ 


/ 


\ 


\<;< 


»° 






294 


58° 
















^ 


1 

1 








280 


56° 










/ 




/ 




k \ 








266 


54° 










/ 5 


? 


/ 




\ 1 








252 


52° 










; 1 




1 












238 


50° 










1 






2 


*\ 


I 






224 


48° 










1 

1 
















210 


46° 








1 




1 








Uq 







196 


44° 








1 

1 




/ 








L \ 






182 


4-2° 








1 

1 




/ 








\ \ 






16S 


.— i -— 


• — — • 


.___ 


_ __. 


••& 


V \ 


-/■ 


veeac, 


f^fO/ 


li'if'H 


-Vfi 1 


yry 


wm — ■ 


-154.., 


38° 








jS™ 




\\ 






IS 


1 


V>3 


a 


140 


36° 




130,, 


I3J^ 


1 




\ 










V \ 




126 


34° 


125 




i 






V 








11 


6^-S 


H* 


112 


32° 






1 






112 












\ 


98 


30° 






1 
1 


















Vdi 


% 84 


28° 






1 
1-2.9 


.5° 


















70 


_'6° 


\ 27 




/ 




















56 


24° 




V 






















42 


22° 




24 


? 




















28 


20° 


























14 



THE SO-CALLED DISEASES OF DENTITION. 



03 



Table II. 

Mortality from Diarrheal Diseases in the City of Buffalo for the Years 
1888, 1889, and 1890 for the Months Named. 

(The interrupted line indicates the average temperature, the continuous line denoting the rise 
and fall of the death-rate.) 



A V. TEMP. 


MAY 


JUNE 


JULY 


AUG. 


SEPT. 


OCT. 


NOV. 


DEATHS 




70° 






/fo 2; 


2 








217 




69° 






/v 










210 




68° 






/ 1 \ 


\ 








203 




67° 




1 




\hl° 








196 




66° 




/ 




k % 

1 % 








189 




65° 




{65° 




\ \ 








182 




64° 




I 




\ia\ 








175 




63° 




1 




"1 








168 




62° 




1 






% 






l6l 




61 ° 




1 






\ 

\ 






154 




6o° 




f 






♦,60° 






147 




59" 


1 








t 
t 






140 




58° 


f 

f 








t 






133 




57° 


f 






t 






126 




56° 


I 






1 






119 




55 ' 


I 
* 






1 
t 






112 




54 ' 


#54? 








\ 1 






105 




53' 












1 




9 s 




5 2 












1 

1 




91 




S 1 










Y82 


1 

1 




84 




50' 












% 




77 




49° 












I 




70 




48° 












1 

1 




63 




47' 












1 

;47° 




56 




46° 
















49 




45° 












\ % 
\ % 




4- 




44° 












\ \ 
V36 » 




35 




43' 












X ' 




28 




A^ 




1 24 










% 


21 




4»° 
















M 




40° 


*3 












» >w9 






39° 














^39° 







64 ORAL PATHOLOGY AND PRACTICE. 

death is not reached until the hot weather of July exacerbates the 
condition, and perhaps adds some kind of fermentative infection 
as the immediate cause of the death, the first degenerative step 
having been taken in the improper feeding of April cr May. 

The teeth have been erupting during this time, and the 
unreflective physician, if he is called in, will quiet the anxious 
parents and friends with the old plea of teething, perhaps lancing 
the gums when no tooth is near eruption, and neglecting the 
organs really at fault, until the sexton closes the scene by burying 
the fatal mistake beneath the churchvard turf. 



CHAPTER XVIII. 
TREATMENT OF THE SO-CALLED DISEASES OF DENTITION. 

It is the first duty of the dentist or the oral physician, when 
he is called to examine the mouth of a child suffering from the 
so-called diseases of dentition, carefully to examine and see if 
there are any indications of disturbed dentition. A correct diag- 
nosis can only be made with certainty after a very careful con- 
sideration, not only of the child itself and the attending symptoms, 
but of its past history, its sanitary environments, and its diet. The 
age should be accurately determined, that it may be seen whether 
the dental development corresponds with that of the general 
system. This is important, because it is not infrequent that morbid 
conditions are ascribed to teething when the teeth due at the time 
are all in place. A medical journal reports a case of infantile palsy 
in a child more than three years of age, as due to teething. Both 
legs were cold and powerless. There was sufficient irritation of 
the gastrocnemius muscles to cause a permanent contraction, thus 
producing a kind of talipes equinus. Nothing is said about the 
state of forwardness of the dentition, but, unless it was unusually 
delayed, the physician, as is 100 often done, jumped at his conclu- 
sions and ascribed to teething a trouble that had a deeper origin. 

The condition of the gums should be carefully noted. If they 
are normal, without any special inflammation or thickening, we 
should look elsewhere for the source of the irritation. It should 
be remembered that the gum is naturally very hard and dense, from 
the large amount of fibrous tissue in it. Normal growth, when 



THE SO-CALLED DISEASES OF DENTITION. 65 

the tooth is near the point of emergence, will find the gum whitish, 
glistening, and tense in appearance. There may be such a condi- 
tion of impermeability, of toughness and hardness in the gum that 
the advancing tooth is retarded thereby, and hence undue pressure 
is brought to bear upon the, as yet, insufficiently protected pulp, 
thus inducing reflex nervous disturbances, but this condition will 
be of comparatively rare occurrence. Unless there are constitu- 
tional and general disturbances that seriously interfere and require 
immediate attention, the tooth easily makes its way through the 
gums, by their absorption under the slight but continual pressure 
induced by the developing roots which lift the crown. 

A clear distinction should, then, be made between those dis- 
eases which are, or even may be, the results of improper feeding, 
and the nervous disturbances caused by retarded or impeded denti- 
tion. Physicians are year by year more clearly recognizing this 
difference and governing their practice accordingly; yet by far too 
large a proportion of them still refer the diarrheas and fevers of 
childhood to teething, and make no special efforts to correct the 
vicious diet which may be the source of the disturbance. 

The treatment of the so-called diseases of dentition properly 
comes within the province of the medical man; yet so frequently 
are young children who suffer from bad feeding brought to the 
dentist for advice or gum-lancing, that some practical general 
directions may with propriety here be given. 

If the gums present their natural light pink, tense, hard, 
glistening appearance, it matters little whether there are or are 
not indications of an advancing tooth; the presumption is that 
there is another cause for the trouble. Retarded or disturbed 
dentition will leave an index upon the tissues about the point of 
irritation, and there will be found some departure from the normal 
appearance. There will be local inflammation, turgidity, and 
tumefaction, with redness and soreness. In the absence of these, 
the diet should be very carefully looked after, hygienic conditions 
inquired into, and in case of any departure from that which is 
proper, the food should immediately be changed and correct sani- 
tary conditions established. 

If there is a simple diarrhea, of not long continuance, with 
little of pyrexia, or fever, a simple correction of the diet will 
probably be sufficient. If the mother shall have weaned the child, 
or her milk is insufficient, some one of the peptonized foods 

6 



66 ORAL PATHOLOGY AND PRACTICE. 

should be substituted. There are so many of these, chiefly pro- 
prietary, that it is scarcely proper to recommend any one above 
the others. It should be something of a very simple nature, in 
which digestion has already been begun by partial peptonization, 
or the diastatic action of some proper digestive ferment. 

A mild cathartic is needed, and this is sometimes the first 
necessity, that the stomach and intestines may be relieved of 
irritating material. Castor oil in doses of from one to three tea- 
spoonfuls may be given. This will especially be indicated if the 
stools are of a green appearance. If, as will probably be the 
case, there is an acid condition, the following may be prescribed: 

1$ — Castor oil, 

Calcined magnesia, of each equal parts. 
Sig. — Dose, half teaspoonful, to be repeated in three hours if necessary. 

Or the following: 

IJ — Pulv. ipecac, gr. ss; 

Pulv. rhei, gr. ij ; 

Sodse bicarb., gr. xij. 

Fiat chart, xii. 
Sig. — One every four to six hours for a child of one year. 
If there are no special inflammatory symptoms, the following 
may be used for the purpose of checking the discharges: 
5 — Tinct. opii. gtt. xvj ; 

Bismuthi subnit., 3ij; 
Mist, cretae, 3jss; 

Syr. simp., Sjss. 

Sig. — Shake well, and give in teaspoonful doses every four hours. 

If spasms are imminent or present, the following may be used: 
IJ — Potas. brom., gr. iij ; 

Tinct. cantharidis, gtt. iij ; 
Spts. camphorse, gtt. x. 

Sig. — Repeat p. r. n. in water. 

In simple diarrhea, after an evacuation of the bowels, the 
following may be prescribed: 

I? — Bismuthi salicylat., 3j ; 
Pulv. ipecac, et opii, gr. x; 
Pulv. aromat., 9j. 

Fiat chart, xii. 
Sig. — One powder every three or four hours for a child of one year. 

If the stools contain mucus and blood and are jelly-like, the 
following may be given: 



REAL DISEASES OF DENTITION. 6j 

IJ — Hydrarg. bichloridi, gr. %.; 
Liq. potas. arsenitis, gtt. xxxij; 
Syrupi rubi, 

Syrupi rhei, aa 5ij ; 

Listerine, adoij. 

Sig. — Fifteen to twenty drops every two hours. If there is much pain, 
add one-half dram of deodorized tinct. of opium to the mixture. 

If there is considerable fever, Dover's powder may be given 
in small doses of one to two grains, or potassium bromid in five- 
grain doses. Sponge baths with tepid water will be found useful, 
and in extreme cases alcohol may be added. 

But the change of diet, and the most careful sanitary precau- 
tions as to the cleanliness of the nursing-bottle, if such is used, 
and of all the surroundings of the child, will be the chief care of 
the physician. Lancing the gums, or other operative procedures, 
will not be found necessary and should not be advised. Usually 
the case will be put in the hands of a general practitioner, but 
the dentist should be competent to prescribe in his absence, or in 
an emergency. 

CHAPTER XIX. 

REAL DISEASES OF DENTITION. 

The real disturbances of dentition are the pathological condi- 
tions accompanying the advent of the teeth, in contradistinction 
to those which arise from improper feeding. Both are sometimes 
of the most serious character, but their origin and the phenomena 
that they exhibit are quite different. Usually, with the eruption 
of the tooth, the superincumbent tissues are absorbed away, and 
give place to tin- erupting organ. It should be remembered that 
up to this time there lias been no formation of alveolar process; 
the bony walls that envelop the germ are very thin and slight, 
and tiny arc not closed over it. There is very little if any pres- 
sure, the fibrous gum tissue offering the only obstacle to advance- 
ment. In normal conditions this is readil) absorbed, but there 
are instances in which, through some malformation of the tooth 
or imperfection of it > tissues, or perhaps because of local disturb- 
ances, considerable pressure is exerted upon the tooth pulp, which 
at this stage of growth forms the greater part of the contents of 
the Crypt, and upon which the enamel and dentinal cap already 

formed are resting. 



68 ORAL PATHOLOGY AND PRACTICE. 

In such instances the tissues will not be in their normal state, 
and will be predisposed to inflammatory conditions. The tooth 
pulp will be especially irritable, and will respond to comparatively 
feeble impressions. 

The pressure that may be exerted upon the susceptible pulp 
in such instances may cause serious complications, but these will 
necessarily be of a reflex nervous character. The irritation to the 
delicate pulp tissue will react upon other tissues, through their 
nerve connections, and various functions may be disturbed. A 
diarrhea may possibly be the consequence, but it will not resemble 
that produced by digestive disorders. The child will plainly show 
nervous irritation; it will suddenly wake from sleep, perhaps with 
a scream. There will be spasms of the facial muscles, and inter- 
vals of pain will be succeeded by entire relief. There will be 
alternate slavering and dryness of the oral cavity. If a diarrhea 
is at times present, it will probably be succeeded by constipation. 
The appetite will be exceedingly variable, and there will be 
present that peculiarly fretful condition that indicates nervous 
irritability. It will be afraid to bite upon anything whatever, and 
will strenuously resist all attempts to touch the gums. This will 
be in marked contrast to the condition when, despite digestive 
disturbances, dentition is proceeding normally. The child then 
delights to bite upon some yielding substance, like the finger or a 
rubber ring. If now the mouth is examined the gums about the 
advancing tooth will be found swollen, red, and turgid, and 
exceedingly tender to the touch. The mucous membrane will 
have lost the pink, tense, and glistening appearance of health, 
and will plainly show its disturbed state. During examination 
the child will perhaps scream hysterically, and plainly indicate its 
exalted nervous excitement. 

When these symptoms and appearances are present, 
no time should be lost in extending surgical aid. Prompt 
and deep scarification over the advancing tooth should be made, 
to divide the swollen gums and disengage the tooth. A crucial 
incision is usually best, if it be a molar, while a longitudinal one 
may answer for an incisor. In either case it should be deep 
enough thoroughly to divide all the tissues over the tooth, and 
extensive enough to free it. If there is any overlapping oper- 
culum of bone, this should be divided, for it will be the greatest 
obstacle in the way of the tooth. 



REAL DISEASES OF DENTITION. 69 

This will usually be sufficient to give immediate and entire 
relief. If the diagnosis of the condition was correct, and the 
incisions sufficient to disengage the whole tooth, the change that 
ensues will sometimes be fairly startling. It may be well to give 
a small dose of potassium bromid (two to five grains), or an enema 
of chloral hydrate (five to ten grains), in water, to quiet the 
nervous excitement and induce sleep, but usually this will not 
be found necessary, the removal of the cause of irritation being 
sufficient. There may occur instances in which the child is in 
spasms, or in convulsions, and the administration of chloroform 
necessary for their control before surgical measures can be safely 
resorted to, in which case there should be no hesitation on the 
part of the operator. 

In any instance of suspected disturbance of dentition, careful 
examination should be made to determine if any tooth is, or should 
be, nearly due, and if it is properly developing. This may usually 
be determined by the app'earance of the jaws, which by their 
growth will indicate it. Many instances have occurred in which 
lancing has been resorted to when no tooth was due for months. 
Mothers, and some general practitioners, will frequently urge 
lancing when there is not the slightest demand for it. In the 
hospital and college clinics of the author, not one case in twenty 
of those presented for it demanded any surgical interference 
whatever. 

The instrument best adapted to the division of the 
tissues over advancing teeth is the curved and pointed 
bistoury. It would be difficult to devise a worse one than the 
ordinary double-edged ovoid lancet, which cannot be made to 
cut at its extreme point. Something that can, if necessary, be 
forced deep down into the tissues at its point, and then drawn 
toward the operator, is essential. A pushing force should never 
be resorted to, as control of the instrument cannot be maintained, 
and there is serious danger of wounding surrounding tissues by 
its employment. 



JO ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XX. 

DENTAL CARIES. 

A popular impression has long existed that caries of the 
teeth is of modern origin, and that it is due to an artificial mode 
of life, to a departure from the laws of nature, and to factitious 
environments. It has been held that our early progenitors knew 
not the pains of toothache, and retained their dental organs to 
a late period of life. The application to these fanciful speculations 
of the facts evolved by actual observation has shown that this 
is an error, and that there is not now and there never has been 
a pathological condition so universal throughout animal life as 
is caries of the teeth, for it is by no means confined to man. There 
are few of our domestic animals in whose mouths careful exam- 
ination will not reveal some form of oral disease,, and among them 
caries plays an important role. Xor is it confined to domestic 
animals; the author has in his possession many skulls illustrating 
this, among them being that of an old male gorilla, with extensive 
decay of the teeth, that has resulted in alveolar and antral abscess, 
with necrosis of the superior maxilla. 

Xo people have yet been found among either civilized or 
savage races in which dental caries was not prevalent. Even the 
most ancient had no immunity, and the skulls of Egyptian mum- 
mies, four thousand years old, exhibit the same decay that is 
observable to-day. Hence we are not dealing with a condition 
that depends upon recent degeneration when we attempt the 
consideration of the subject. It is as old as the human race, and 
has probably caused more of pain and distress to the human family 
than any other disease with which man is afflicted. 

It would naturally be expected that a condition so universal, 
so ancient in its origin, and so distressing in its results would 
have been carefully studied, and long since thoroughly compre- 
hended. The fact really is, that until within fifteen years almost 
nothing was known of the real etiology of caries, or of the changes 
it involved. Speculation there had been in abundance, and many 
ingenious theories had been evolved, none of' which satisfied the 
existing conditions. It is within the memory of even compara- 
tively young practitioners, when at our dental associations and 
meetings the most contradictory hypotheses were advanced. It 



DENTAL CARIES. J I 

was declared to be the effect of an inflammatory process of the 
tooth tissues. It was ascribed to mineral acids that dissolved out 
the calcic salts of the teeth. It was by some believed to be due 
to a perverted nutrition, whereby there was a breaking- down 
instead of a building up of tooth elements. It was claimed to be 
the effect of a lack of mineral elements in the food during the 
period of growth. In fact, the etiology of caries was a common 
battle ground, on which the advocates of the different theories 
met to try conclusions, without the possibility of victory for either 
combatant through the positive establishment of any special 
hypothesis. 

With the comprehension of the true principles of fermenta- 
tion and the advance of bacteriological knowledge, light began 
to dawn on the dark places, until at last by the exhaustive 
researches of Prof. Dr. W. D. Miller, an American dentist resident 
in Berlin, the problem of the ages was finally solved, and the 
true nature of dental caries was determined. It was found that 
those who had described it as a decalcification through the action 
of an acid were partially correct, but greatly mistaken as to the 
source of the acid. The advocates of the vital hypothesis had a 
section of the truth, but not enough upon which to base a practice. 

Miller demonstrated that dental caries is due to a number of 
factors, but the principal and basal one is the growth of oral 
bacteria. 

it has been shown in a previous chapter that the mouth is 
especially adapted to the growth of micro-organisms. Here are 
found the proper temperature, the most fitting media, and the 
required moisture; the temperature is as evenly maintained as 
it ran be in any incubator, while the proper soil for their prolifera- 
tion is always provided. The various foods, especially the 
starches, will by the action of the ferments of the mouth be 
changed into forms admirably adapted to the growth of the acid- 
forming bacteria. Of some of these Miller made cultivations, 
analyzing their by-products, and he found, as the result of the 
proliferation of one special organism, lactic acid. Further obser- 
vation enabled him specifically to point out the exact method by 
which caries is produced, which Is as follows: 

In the sulcus of a tooth, or between two teeth, or in any pit 
or irregularity of its surface, food lodges. By the action of some 
ferment, this is perhaps changed into sugar. This forms a suitable 



J2 ORAL PATHOLOGY AND PRACTICE. 

medium for some of the bacteria, and it is perhaps at once infected 
with the "Delta" organism of Miller. In its growth this splits up 
the fermentable sugar, building into its own substance such ele- 
ments as are necessary for it, and leaving the remainder to form 
new combinations, or by-products, one of which is lactic acid. This 
acid, especially active in its nascent or formative condition, attacks 
the teeth, dissolving out the calcic salts, and forming a depression 
in which more food lodges, to pass through the same changes and 
to be in turn decomposed by new colonies of bacteria, thus forming 
more acid to continue the destructive work. 

The dissolving out of the calcareous parts of the tooth 
leaves behind the organic or living portion, which may pass 
through inflammatory or degenerative stages, finally to be de- 
stroyed by putrefactive organisms. This is the essential principle 
of Miller's discovery. The enamel once penetrated by the pro- 
ducts of the growth of the vegetable fungus, the progress of the 
disorganization is more rapid. 

The bacteria penetrate the dentinal tubuli ; the acid 
generated within them, through the action of the micro- 
organisms, enlarges the tubules, melting down two or 
more into one, thus forming minute chambers or cavities 
in the dentin, which ultimately are blended into a yet 
larger one, and thus decay proceeds. Microscopical exam- 
ination shows these small spaces to exist at a considerable distance 
beyond that which is actually broken down, and to account for the 
friable, crumbling dentin about the margin of the cavity proper. 

The area denominated by Miller "the zone of infected dentin" 
is that pervaded by the organism, but in which the dissolving out 
of the calcareous inorganic matter of the tooth has not yet fairly 
commenced. 

Yet farther into the structure of the tooth have penetrated the 
bacteria, filling the tubuli without having distended them. Not 
infrequently a number of these distinct zones of infection or 
caries are seen in their different stages, and readily traced. They 
are all the result of tooth infection and tooth decalcification through 
the action of bacteria. 

Miller, having demonstrated the true nature of this disease 
by analytical methods, next attempted a kind of synthesis, arriv- 
ing at the same result; thus by an independent process proving 
the correctness of his previous observations. Obtaining a pure 



DENTAL CARIES. 73 

culture of the bacillus of decay, he immersed an extracted tooth 
in a proper culture solution, and with the utmost solicitude keeping 
it in the proper condition and at the exact temperature, he infected 
it with the bacillus and produced true caries outside the mouth 
and removed from all physiological or vital connections. He thus 
demonstrated that caries is not a vital process, and that the pro- 
liferation of the bacillus under proper conditions will produce it 
as readily outside the body as in it. 

It must, then, be accepted as finally proven that dental caries 
is the result of an infection, and a true germ-produced disease. 
It is essentially a septic condition, and its medicinal treatment 
must be antiseptic. All prophylaxis must be in this direction, 
and the general principles of Listerism are as applicable to caries 
as to the treatment of wounds. To proceed farther than this in 
the consideration of the etiology of dental caries would be outside 
the scope of this work. 



CHAPTER XXI. 
DENTAL CARIES (Continued). 



Physiologists, pathologists, and histologists are inclined to 
consider the teeth as organs isolated, dissociated from the rest 
of the body, as of such dissimilar, diverse characteristics that 
their relation to other tissues is but a minor factor in their study. 
Dental practice has been too exclusively confined to the teeth 
themselves, reputable practitioners asserting openly that there is 
no need for the dentist to study general anatomy or physiology, 
and protesting against everything save the very narrowest and 
most restricted teachings in our colleges. Almost unconsciously 
the greal body of practitioners have been led to think of the teeth 
as segregate organs. There are many of our number who, while 
claiming professional relationship, treat their vocation as exclu- 
sively mechanical, and unwittingly debase their own condition to 
that of a mere artisan. 

The teeth are true modifications of bone. The study of com- 
parative dental anatomy teaches through what gradations they 
have passed; very many of the intermediate steps are recorded 
in the oral or pharyngeal cavities, and even in the gastric regions, 



74 ORAL PATHOLOGY AND PRACTICE. 

of animals now extant. In some instances mastication is abso- 
lutely performed upon true bone, of compact structure, which, 
however, is soon lost if it is submitted to any rough usage. We 
sometimes marvel that the teeth decay as they do. Were they 
not differentiated in their structure from the bone of which they 
are only modifications, they would not last as long as they do. 

That the teeth are vital organs, with a vital dependence upon 
other tissues, that they are intimately connected with the rest of 
the body, is readily indicated by the fact that they are nourished 
by the same blood supply and receive their innervation from the 
same nervous system with the other organs. It is true that they 
are the hardest, densest tissues of the body, but in this they differ 
comparatively little from true bone. They are made up of a 
living matrix, into which calcium salts have been incorporated 
to give to them consistency. They are developed from the same 
connective tissue elements with other analogous tissues. They 
only differ from bone in having a little more of the calcic salts 
and a little less of the living matter, in this respect the different 
tissues of the teeth showing the same variations that are observable 
in different kinds of bone. To illustrate this the following table 
is presented: 

Bone. Cementum. Dentin. Enamel. 

Animal matter 3400 32.00 28.00 5.00 

Earthy matter 66.00 68.00 72.00 9S-00 

100.00 100.00 100.00 100.00 

Calcium phosphate 5104 56.73 62.00 85.00 

Calcium carbonate n.30 T.2.2 5.50 8.00 

Calcium fluorid 2.00 1.63 2.00 3.20 

Magnesium phosphate 1.16 0.99 1.00 1.50 

Sodium salts 1.20 0.82 1.50 1.00 

This table gives but an average of the proportional constitu- 
ents of the tissues. It would be well if a careful study of it could 
be made by every dentist. It will be seen that the same elements 
enter into the composition of all the hard tissues. 

The essential variation of tooth tissue from true bone is that 
through the progressive modifications of cementum, dentin, and 
enamel there is a gradual loss in the proportion of animal or organic 
matter, and a proportionate increase in the earthy or inorganic. 
This is most manifest in the calcium phosphate, upon which the 
teeth mainly depend for their density and hardness; there is 



DENTAL CARIES. 75 

comparatively little variation in the relative amounts of calcium 
carbonate, magnesium phosphate, and the other salts. In bone 
the living matter is nearly half that of the inorganic, while in 
enamel it is but one-nineteenth. 

But it is not alone in its constituent elements that the 
modifications of tooth from bone are exemplified. In their 
physical structure the gradation is still more marked. In bone 
the most distinguishing feature of the nutritive apparatus is the 
Haversian canals, about which are arranged in concentric group- 
ing the cells containing the living matter. These corpuscles, the 
lacunae, communicate with each other and with their source of 
nutrition by minute canals, the canaliculi. Each regular arrange- 
ment or system of these communicating lacunae is called a 
lamella, and these in turn are in relation with each other through 
connecting canalicnli. 

The first modification, or differentiation, is found in 
the cementum, which has all the distinguishing features 
of bone, if we except alone the lamellae. . The lacunae are 
present, and the canaliculi; even the Haversian canals are some- 
times found. They are not as constant as in true bone, but even 
in that they are not always present. The lamellar, concentric 
arrangement of the lacunae about the Haversian canals is alone 
lacking, and this is the case even when these vascular canals are 
found in tin- cementum. The proportion of animal and earthy 
matter has been but slightly changed, the variation between differ- 
ent bones being sometimes greater than that between bone and 
cementum. Cementum, then, essentially differs from bone only in 
the loss of the lamellar arrangement of the cells. 

The next step in the differentiation is found in the 
dentin, which has lost the lacunal corpuscles that distin- 
guish cementum and bone. As these contain the greater pro- 
portion of tlie living matter, we naturally anticipate a considerable 
deficiency in that clement, and analyses show that it has but about 
four-fifths the amounl found in hone, while the earthy salts are 
correspondingly increased. In its physical structure, then, dentin 
retains bul the canaliculi of bone, and these appear in their 
analogues- the dentinal fibrillae. [nstead of being the channel 
of communication between the lacunae, a- in bone and cementum, 
they serve to connect the pulp, the a of the medulla of 

bone, with the cementum, the ultimate dependence not being very 



76 ORAL PATHOLOGY AND PRACTICE. 

apparent. As in bone and cementum, they are the medium of 
nutrition to the interstitial parts and the parenchyma. Dentin, 
then, is bone modified in structure by the disappearance of the 
lacunae, as well as their arrangement into lamellae. 

Finally, enamel is developed, — the densest, hardest, heaviest 
tissue of the body. This is that which alone is exposed to attri- 
tion, and to the direct action of foreign substances. 

Bone, cementum, and dentin are normally protected from 
exposure. If the former is uncovered, even to the external air, the 
most serious consequences may follow. Cementum is a little, and 
dentin considerably more tolerant of submission to external influ- 
ences. But neither of them accepts it without a pathological 
protest. Enamel alone successfully withstands external contact, 
and even that is in better condition when in possession of its 
natural covering, cognate to the skin and mucous membrane, 
Nasmyth's membrane. 

The very circumstances under which enamel exists must 
demand a material modification of structure. Accordingly we 
find that not only the lacunae of bone and cementum are lost, but 
the canaliculi of bone, cementum, and dentin have disappeared, and 
the principal remnant of the living matter left is the microscopical 
septum between the enamel prisms. But it is not dead, inert 
matter. Three per cent, of its structure is animal, so that, tenuous 
as is the thread, it has yet a vital connection with the other living 
portions of the body. The necessities of its existence demand 
that it shall have but a very minute proportion of animal matter 
to protect it against the exposure and rough usage which it must 
receive, but still it is identical with bone in its constituent elements, 
though widely variant in their relative proportions. 

Enamel is bone deprived of the lacuna: and canaliculi, cut off 
from its generic organ, without independent nutrition, but still retain- 
ing a proportion of that animal matter without which it z^'ould be 
something alien and foreign. 

It is from this standpoint that the tissues of the teeth are 
properly considered. It is in their relation to other tissues, and as 
a part of the living organism, that they are to be studied. The 
teeth are not lifeless, passive, extraneous objects. They have 
their pathological degenerations that demand medicinal agents. 
Their treatment cannot properly be exclusively surgical or op- 



THE MEDICINAL TREATMENT OF DENTAL CARIES. -]-] 

erative. It is true that their nutrition is limited and sluggish, 
but it exists, and must be considered. They are amenable to the 
same general laws with the rest of the body. They contain a 
large proportion of inorganic matter, but even that must be elab- 
orated in the alembic of nature, — it cannot be taken ready-made; 
the calcium phosphate that forms so great a part of their body is 
of organic origin, and was distilled by nature's process from the 
organic matter that alone can be used as food or built into the 
system. 

Every tissue of the tooth, as is the case with all other 
tissues, is the product of growth, hence is truly organic, and 
the assimilative processes can no more accept for nutritive 
purposes such inorganic matter as crude calcium phosphate 
than it can utilize carpet tacks to give iron to the blood, or 
lucifer matches to furnish phosphorus for the brain. Such 
preparations may act as medicines, to be excreted as received, but 
their administration for metabolic purposes is an utter absurdity. 

That an hereditary tendency may be a factor in the etiology 
of dental caries, no one will for a moment dispute. One may 
inherit a diathesis, a congenital atonicity or a lack of resistant 
power, but a bacillus is not received as a patrimony. Modern 
investigation proves that so many of our disorders are of infec- 
tious origin that the doctrine of heredity must be materially 
modified. Prof. G. V. Pluck, by his experiments, has demon- 
Strated that there is less of difference in the structure of so-called 
good and bad teeth than has been usually imagined. This throws 
US more directly back upon the vis medicatrix naiitrcc for our cures, 
and places us in a more intimate relation than ever with the vital 
principle, the innate resistant power of the body, and directs our 
thoughts into new channels. Dental caries must be studied from 
the vital standpoint, and in this view we approach the subject. 



CHAPTER XXII. 

THE MEDICINAL TREATMENT OF DENTAL CARIES. 

It having been demonstrated that caries of the teeth is chiefly 
due to the action of micro-organisms, it naturally follows that the 
remedies employed, aside from operative ones, — which it is not the 



78 ORAL PATHOLOGY AND PRACTICE. 

province of this work to consider, — must be mainly antiseptic. 
Were it possible completely to sterilize, and to keep sterilized, the 
oral cavity, there could be no decay. But this is impracticable, 
and even undesirable. The peptonizing action of many of the 
bacteria may be an important factor in digestion, hence it may not 
be best, even if it were possible, to eliminate them. But of the 
advisability of at least limiting their action there can be no ques- 
tion. The putrefactive organisms certainly can have no useful 
office in the mouth, and common cleanliness demands that their 
growth should, as far as possible, be prevented. 

Could the teeth and the oral tissues be kept entirely 
clean and free from food and other debris, caries would be so 
limited that it would be of little moment. A carefully polished 
surface does not retain detritus or debris. Unless there are depres- 
sions, or pits, or roughness, there is nothing to which particles of 
food can cling. It is evident, then, that the first prophylactic 
measure against caries is the careful polishing of the teeth. 
Every deposit upon them must be removed, every pit obliterated, 
and every rough surface made entirely smooth. This will be the 
work of the dentist, but the keeping of them in that state will 
depend upon the exertions of the individual himself. A set of 
natural teeth in a state of perfect cleanliness is a sight seldom 
vouchsafed to anyone. Quite as rare would be a patient, just from 
the chair of the dentist, whose teeth had been put in perfect order. 
The average practitioner neither recognizes nor attempts the cure 
of half the pathological conditions that exist in the mouths that he 
treats. He fills the most conspicuous cavities, removes deposits 
that actually obtrude themselves upon his notice, and ignores the 
rest. Nor is it necessarily his own fault in every instance, for 
patients sometimes might offer serious objections to expending 
the time and money necessary for the treatment of all diseased con- 
ditions and the putting of the mouth in complete order. 

There is, however, no excuse for failing to call the attention of 
decently clean people to minute sedimentary precipitations upon 
the teeth, depressions or erosions of their surfaces, and inflam- 
mations and irritations of the soft tissues about them. That which 
is neglected is mainly in the line of prophylactic treatment. Were 
dentists generally more faithful to duty, their practice would be 
widely extended, while the people would be greatly benefited. 



THE MEDICINAL TREATMENT OF DENTAL CARIES. 79 

It is unnecessary to call the attention of the student or practi- 
tioner to the most approved methods of cleaning the teeth. That 
duty devolves upon the teachers of operative measures. But the 
proper medicinal agents may be adverted to, and their use recom- 
mended. In the performance of this task it is impossible entirely 
to avoid mention of proprietary remedies, whose employment, 
when others can be substituted for them, should be eschewed; 
yet they are sometimes a convenience, and, when the formula is a 
public one, may be professionally prescribed. A convenient, effec- 
tive and unobjectionable antiseptic mouth-wash, consisting of a 
single simple remedy, is almost unknown. The most efficient 
germicides possess toxic or caustic properties that are sufficient to 
exclude them. The best antiseptics are liable to the same objec- 
tions, and we are thus forced back upon the essential oils, which 
must be combined with other things to make them most useful. 
Listerine, borine, borolyptol, and other combinations are proprie- 
tary preparations, and therefore objectionable on ethical grounds, 
for no physician has any right to make a prescription for a patient 
unless he is fully aware of its entire character and thoroughly con- 
versant with every drug in it. He is paid for the expert knowledge 
of which the patient is not possessed, and he betrays that patient's 
professional confidence if he does not exercise entire intelligence. 
Hence proprietary and secret remedies have no place in this work 
unless their complete working formulae shall have been submitted 
to and approved by the author. 

For antiseptic use in the mouth, lysol presents some advan- 
tages, and the following may be used with the tooth-brush: 

IJ — Lysol, Bss; 

Aquae, oxvj. 

Carbolic acid is not palatable, and it possesses toxic properties 
that forbid its use in strong solutions. But it is excellent as an 
antiseptic, and the following formula may be found useful: 

It — Carbolic acid crystals, 
Glycerol, 
Rose water, of each 2 1 mnces. 

Five to ten drops in a wineglass of water should be used as a 
gargle, or wit]] the brush. 

Thymol is similar in its action to carbolic acid, while it is free 
from its disagreeable odor. 



80 ORAL PATHOLOGY AND PRACTICE. 

I£ — Thymol, 4 grains; 

Benzoic acid, 45 " 

Eucalyptol, 180 " 

Water, 2 quarts. 

This should be used as a gargle, after cleaning the teeth. 

The following is recommended by Professor Miller as an anti- 
septic gargle and wash : 

I£ — Thymol, 4 grains; 

Benzoic acid, 45 " 

Eucalyptol, 3 J/2 drams; 

Alcohol, 25 " 

Oil of wintergreen, 25 drops. 

Hydronaphthol has been employed as an antiseptic, but was 
formerly more used than it is at present. The following formula 
has been recommended for a mouth-wash : 
IJ — Hydronaphthol, 3ij ; 

Tinct. calendula:, 3iv; 

Aquse dest., adoviij. 

Any of these may be used with the tooth-brush, or as a gargle 
after cleaning: the teeth. 



CHAPTER XXIII. 
PULPITIS— INFLAMMATION OF THE DENTAL PULP. 

Save as it is modified by surrounding conditions, inflammation 
of the pulp does not differ from that of other analogous tissues. 
The initial processes are the same, and hence the remarks in the 
section on Inflammation are applicable to the condition now under 
consideration. When the subject of general inflammation is fully 
comprehended, then, and then only, can the phenomena presented 
in pulpitis be clearly understood. It is but necessary to consider 
the peculiar complications brought about by the environments 
of the dental pulp, and to make due allowance for them, when the 
whole matter becomes plain and lucid. These complexities arise 
from the fact that the tissue of the pulp is somewhat modified 
in structure, and at the same time is enclosed within unyielding, 
osseous walls, which in health form its sure protection and in 
disease its rigorous prison-house. 

Whether or not the dental pulp, in its healthy, normal condi- 



INFLAMMATION OF THE DENTAL PULP. 8l 

tion, is or is not sensitive to external impressions is a disputed 
question which cannot be satisfactorily answered, because if it is 
responsive it is at once claimed that it is not in a normal condi- 
tion. Certain it is that an entirely healthy tooth gives no sentient 
signs of the presence of a living pulp. It is sometimes a difficult 
matter positively to diagnose a dead pulp from a healthy living 
one in certain conditions. Both are equally unresponsive to 
ordinary thermal changes, and the enamel and dentin of each 
are equally insensitive. 

Those who have had occasion to drill into or excavate a tooth 
that is entirely without disturbance of the pulp tissue, know that 
the dentin is unresponsive, while the pulp may be, and often is, 
punctured without the knowledge of the patient. 

But if there is recession at the gums, or if there shall 
have been any pain in the teeth whatever, indicating pulp 
complications, or even any pulp disturbance insufficient 
to produce pain, both dentin and pulp may be exquisitely 
sensitive. There are many instances in which, caries has ex- 
tended to the pulp tissue, but in which there never has been either 
pain or sensitiveness. This cannot be reasonably accounted for 
upon the theory of personal idiosyncrasy, for individual tempera- 
ment will scarcely cover a departure from general physiological 
laws. There must be a good and sufficient reason for such an 
immunity. 

The blood vessels of the pulp possess a modified structure, in 
that they are without the complete muscular coats of those found 
in most parts of the body. In this respect they resemble those 
of the brain, which also is a tissue protected by unyielding, bony 
walls, analogous to those of the tooth. The nerves of the dental 
pulp are also modified, for while they are composed of nervous 
elements they lack the general structure of those of most other 
parts of the body, and they are without the usual sheaths. The 
connective tissue of the pulp is not especially modified in struc- 
ture, but it must be peculiarly so in function, through its excep- 
tional blood and nerve supply. These variations will be specially 
considered in the chapter devoted to the diseases of the peri- 
cementum. 

The dentin is without nerve supply, and yet when in 
an irritable condition it becomes acutely responsive. Sen- 
sation ran only be conveyed through the dental fibrillae, whose 

7 



82 ORAL PATHOLOGY AXD PRACTICE. 

embryonal structure, containing all the elements of nerve tissue, 
becomes inordinately responsive in certain conditions. It is well 
established that formative tissue, embryonic matter, may take on 
inflammatory conditions, and under such circumstances possess 
characteristics unknown to it when in a normal state. 

It might be reasonably inferred, then, that the sensitive- 
ness of either dentin or tooth pulp may be the direct result 
of irritation, and the inceptive stage of an inflammatory 
process; that sensitiveness of dentin is but the result of that 
abnormal, irritative, inflamed condition; that the peculiar 
phenomena presented are due to the modified blood and 
nerve supply, and that in its normal and healthy state it 
may be quite irresponsive to external impressions ; that 
any special responsiveness of either of the tooth tissues to 
external impressions is an indication of a pathological con- 
dition, and that in treatment this should always be kept in 
view. 

The pathological changes presented and the phenomena 
exhibited in inflammation of the tooth pulp will differ from the 
corresponding phenomena in most other tissues just so far as the 
structure of these latter is varied and their environments are modi- 
fied by the tissues with which they are in relation. The peculiari- 
ties of the nerve supply will change the character of sensation, 
while the special vascular system will vary the phenomena pre- 
sented in the earlier stages of inflammation, and materially modify 
diapedesis. Proceeding upon this hypothesis, it is not difficult to 
comprehend some things heretofore unintelligible in the pathology 
of the dental pulp, and to find indications that may be a more com- 
plete guide in diagnosis and treatment. 

A specially sensitive tooth is one whose tissues are in an 
irritable condition, and this is either the initial step in, or a 
positive stage of, an active inflammation. The irritant may be 
any one of a long list. 

/. Caries has perhaps invaded the tooth, and micro-organisms 
have penetrated the tubitli, becoming themselves the irritant, or expos- 
ing the deeper dentin and pulp to the irritating action and thermal 
changes of external agents. 

2. It may be that an inserted filling is this outward irritant. 

j. There may be recession of the protecting gum tissue at the 
cervical portion of the tooth. 



INFLAMMATION OF THE DENTAL PULP. 83 

4. A traumatic injury, a blow, inordinate use, the attrition of 
mastication, or any mechanical violence may be the source. 

5. Structural changes within the tooth pulp, such as the forma- 
tion of calcific deposits, are a sufficient excitant. 

Whatever the cause may be, there will be a determination 
of blood to the irritated pulp tissue and an engorgement of its 
capillaries. Because of the absence of the usual arterial and 
venous coats, the blood channels at once yield to the pressure. 
There is not the usual vaso-motor system of nerves to control 
the resilience of the vascular system, and diapedesis, or the escape 
of the elements of the blood into the pulp tissue, is materially 
modified. It does not at once take place in the usual acceptance 
of the term, but a stage of active engorgement of the blood 
channels ensues. 

The dental pulp is without the full and complete chain of 
lymphatics of the absorbent system, because the modification of the 
blood supply in a measure makes it unnecessary. The compara- 
tively unrestrained yielding of the blood channels, and the retarda- 
tion of the infiltration of the pulp tissue allows for a return to a 
physiological state, if once the irritations cease, without the neces- 
sity for the usual process of resolution through the activity of the 
lymphatics in relieving the hyperplastic condition. It follows, 
then, that the treatment of ordinary pulpitis, after the removal of 
the irritating cause, should be directed towards the relief of the 
congested condition by deflecting in some manner the determin- 
ing blood current and allowing the engorged vessels to empty 
themselves. So long as the possibility for this exists, it is quite 
possible to preserve the vitality of an inflamed pulp. 

When the pathological condition shall have proceeded to the 
extravasation into the body of the tissue of inflammatory products, 
the lymphatics are not able to take them up, and their removal is as 
impossible as is that of any great effusion in the brain. Pulp cap- 
ping under such circumstances will be a hopeless proceeding, and 
the presence of any infiltrated or effused matter will contraindicate 
it. The fact that some pulps become fully exposed and their 
investing tooth walls an- broken down without either pain or 
special sensitiveness ma\ In- accounted for through their never 
taking upon themselves real inflammatory conditions, because of a 
modification <>t" nerve structure greater than that which is usual. 



84 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XXIV. 

TREATMENT OF INFLAMMATORY CONDITIONS OF THE 
DENTAL PULP. 

Usually, the first indication of irritation of the dental pulp 
is responsiveness to external impressions, manifested by a sensi- 
tiveness to thermal changes. Cold air or cold water cause pain of 
a sharp, lancinating character. Xot infrequently the neck of the 
tooth, or any abraded surface, is also sensitive to any outward 
irritant, such as a metal tooth-pick or instrument. This indicates 
dentinal irritation. The responsiveness to thermal changes in- 
creases and becomes more persistent, until there is a distinct 
odontalgia or toothache. This pain will be rather paroxysmal, 
returning upon slight provocation and passing away in a few- 
moments. It may be difficult for the patient to determine exactly 
which tooth is affected, because of its sympathetic nature and 
because it is distributed over a considerable territory. Suc- 
cessively isolating each tooth by the rubber-dam, and the applica- 
tion of alternate heat and cold, will, however, usually determine 
the matter. Sometimes there is a response to percussion, and a 
diagnosis may thus be reached. This earlier stage will be that 
of hyperemia, and the beginning of engorgement, or congestion. 
The exalted sensibility is due to the irritable condition of the 
nerve tissue. If relief is not obtained, the pain, with the exacerba- 
tion of the inflammatory condition, becomes more intense and 
continuous. With the increased engorgement the pulp, which is 
held immovably within the bony tooth walls, becomes intensely 
irritable, and the pain instead of continuing remittent becomes 
almost continuous. The lancinating flashes can no longer be dis- 
tinguished, but are so quick in succession as to be practically unin- 
termittent, and there is at the same time a deep, boring pressure 
felt, which indicates that the inflammation is passing to its second 
stage, that of effusion, in which there is a passing out of the ele- 
ments of the blood into the tissues. 

Up to this point the vitality of the pulp may readily be pre- 
served, if active measures are taken for the relief of the inflam- 
matory condition. This stage once passed, and extravasation into 
the pulp tissue having taken place, the probabilities are largely 
against conservation. 



TREATMENT OF INFLAMMATORY CONDITIONS, ETC. 85 

About this time the pain changes its character somewhat and 
it is not of such a sharp, lancinating nature. It becomes more 
steady and less paroxysmal. There is a greater feeling of pres- 
sure, and it is more readily located. The pulsation, which up to 
this time is very distinct, now ceases. The congestion soon reaches 
its height, and entire stasis of the blood current in the pulp is immi- 
nent. Cold is no longer irritative and warmth grateful. The 
opposite condition ensues, and ice water will relieve the pain, while 
any warm application exacerbates it. The suffering caused by the 
affected organ is intense, but the end is probably near at hand. 
With complete stasis sensation is gradually lost, the pain pro- 
gressively abates, neither cold nor heat aggravate, and the tooth 
is irresponsive to any ordinary irritant. The inflammatory process 
has run its destructive course, and the pulp is dead. This is the 
usual train of symptoms and the ordinary progress of the disease. 

The treatment in the earlier stages should be abortive. The 
first essential is to make a clear diagnosis of the case, by carefully 
considering all the symptoms. The exact stage of the disease 
should be determined if possible. This having been done, the 
next point will be to remove the cause. If it is progressive caries, 
the cavity of decay should be carefully washed out, all debris 
removed, and an anodyne introduced. If any foreign substance 
is the irritant, it must at once be eliminated. The tooth must be 
relieved of all labor of mastication and given entire rest. Counter- 
irritants, such as iodin and aconite, or capsicum bags and plasters, 
are useful by promoting metastasis; that is. a new focus of inflam- 
mation is created in an approximate territory, but which is upon 
the surface where it can be reached and where resolution may be 
expected. This has a tendency to divert the impending blood cur- 
rents, and thus to relieve the threatened engorgement of the pulp. 

Hot pediluvia, or foot-baths, should be prescribed, the water 
to be as hot as can well be borne, and these to be continued for 
at least thirty minutes, for the purpose of equalizing the circula- 
tion and relieving the plethoric condition of the pulp. 

Saline cathartics are useful, because they reduce the blood 
tension, removing from the sanguinary fluid a portion of its 
watery constituent, and thus greatly diminishing the stress. 

Diaphoretics are perhaps the most important of the general 
remedies. They not only extract a considerable amount of water 
ii"' >m the system and fn im the blood current, but they act as general 



86 ORAL PATHOLOGY AND PRACTICE. 

depurators, promoting healthy functional action and removing 
local obstructions. 

Anodynes are indicated, because they equalize nervous func- 
tion and tend to restore the proper tone to the arteries and veins 
through the vaso-motor system, and to allay the general nervous 
excitability. 

Probably there never was a case of pulpitis that would not 
yield, temporarily at least, to the vesicant action of a powerful 
counter-irritant at the back of the neck, a foot-bath continued for 
thirty minutes, and twenty to forty grains of potassium bromid. 
Such drastic measures are not often called for, and are inadvisable 
when milder means will suffice. 

Any of the preceding measures may be resorted to in cases 
in which there is no actual or threatened exposure of the pulp 
through progressive caries, or by accident. When there is a large 
cavity of decay, it must first of all be thoroughly opened up, and 
all debris and foreign substances removed as carefully and as 
completely as possible. It should next be washed out with tepid 
water in which a little salt has been dissolved, by injecting the 
stream from a mouth syringe. The cavity should be dried out, 
and a pledget of cotton dipped in oil of cloves, or dilute creosote, 
or hamamelis inserted, this to be carefully sealed up without pres- 
sure, by means of gutta-percha or a pledget of cotton dipped in 
chloro-percha. A solution of sandarac in which to dip the cotton 
should not be employed, because it insecurely seals it and because 
it very soon decomposes, leaving the cavity in a worse state than 
at first. It is also likely to encapsule the remedy, and thus to 
isolate it and preclude its action. 

If there is actual exposure of the pulp tissue, after the cavity 
of decay has been opened up and carefully cleaned and washed 
out, the rubber-dam should be applied, the opening dried out by 
means of hot air, and the pulp and cavity walls sterilized by the 
application of mercuric chlorid, solution i to 2000, or some other 
effective germicide. If there is considerable congestion, a pledget 
of cotton dipped in the following may be carefully placed over 
the point of exposure and sealed up: 

E — Plumbi acetatis, gr. v; 

Tinct. opii, 3ss; 

Aquce, oij. 

This should be allowed to remain for some hours, when it may 



TREATMENT OF INFLAMMATORY CONDITIONS, ETC. 87 

be changed for a dressing of dilute oil of cloves or of cassia. All 
pain will usually cease with the application of an anodyne. When 
more active measures are demanded, the following dressing may 
be applied after the sterilization: 

R — Atropinse sulph., gr. j; 

Aquae dest., oj. 

If the pulp shall have been wounded and bleeding ensue, or 
if there is exudation of serum from the exposed pulp, it may be 
dressed with a solution of tinct. iodin and persulphate of iron 
in equal parts. Tinct. opii may sometimes be necessary for the 
purpose of soothing the disturbed tissue. The inflammation and 
congestion once relieved, the necessary operative measures for the 
further preservation of the tooth may be instituted. If there is 
no actual nulp exposure these may, if skillfully executed, be con- 
fidently relied upon to serve their full purpose. If, however, any 
portion of the pulp tissue is really uncovered, the prognosis will 
not be as favorable. In the earlier stages of inflammation, before 
there is any exudation from the blood vessels of the pulp, the 
best results may be predicted. If there has been extravasation of 
the contents of the blood channels into the body of the pulp absorp- 
tion cannot be expected, owing .to the absence of lymphatics, and 
breaking down of the tissue or death of the pulp will result. 

The successive stages in degeneration may be tabulated as fol- 
lows: 

First Stage. Second Stage. Third Stage. Fourth Stage. 

Symptoms Sensitiveness. Pain (cold ex- Pain (cold Insensibility. 

acerbates). relieves). 

Condition Irritation. Inflammation. Infiltration. Stasis. 

Pathology Hyperemia. Diapedesis. Congestion. Death. 

Prognosis Good. Doubtful. Bad. Hopeless. 

The different remedies in the several classes that will prove 
best adapted to dental practice may be summarized as follows: 

Food Laxatives. — Green and dried fruits, cracked wheat, oat- 
meal, etc. 

Medicinal Laxatives. — Seidlitz powder, castor oil (doses for 
adults of 4 to 8 drains, and for children i to 3 drams), lac. sulphur 
i\ to 3 drams, in syrup or milk). 

Saline Cathartics.— "Epsom salts (2 to 8 drams in carbonated 

■ >, citrate of magnesia (dose according to preparation). 

Diaphoretics. — Warmth and exercise, cold drinks. Dover's 



88 ORAL PATHOLOGY AND PRACTICE. 

powder (5 grains), spirits of Mindererus (2 to 8 drams every two to 
four hours), sweet spirits of nitre (2 to 4 drams frequently). 

Diuretics. — Diluent drinks, mineral waters, beef tea, whey, 
gruel, cream of tartar (r to 4 drams combined with \ dram bibcrate 
of soda), borax (20 to 40 grains). 

Anodynes. — Potassium bromid (5 to 20 grains), sulphate of 
morphin \ to \ grain), aromatic spirits of ammonia (10 to 60 
drops). 



CHAPTER XXV. 



PERICEMENTITIS— INFLAMMATION OF THE PERIDENTAL 
MEMBRANE. 

Sometimes this affection is closely connected with inflamma- 
tions of the dental pulp, and it may be derived from mere con- 
tiguity or proximity of tissue. Usually, however, it arises quite 
independent of the other disorder, and indeed is more severe when 
the pulp has been devitalized, either by design or disease. 

The pericementum is an exceedingly vascular organ, and it 
has an abundant nerve supply. This is necessary to its proper 
functional action. It is the placental organ which affords the 
pulp of the tooth its vascular and nervous supply. The text-books 
and preparations which represent the arteries and veins of the 
tooth pulp as passing out at a single foraminal opening and travers- 
ing the tissues until they anastomose with some larger vessel of 
which they are branches, and which is not in relation with the 
tooth at all, are misrepresentations of the actual condition. No 
blood vessel or nerve can be directly traced beyond the investing 
pericemental membrane. 

The foraminal opening of the normal tooth root is not a single 
direct aperture, having its axis in line with that of the pulp, but, 
especially in early life, is a delta with a number of communicating 
origin, which begin to diverge at about the apical junction of 
the dentin and cementum, and with a kind of circular sweep reach 
the pericemental membrane, with whose blood vessels the branches 
from the dental pulp anastomose. Indeed, in early life the ana- 
logues of Haversian canals are not infrequently found penetrating 
the cementum and dentin at different points along the periphery 
of the tooth root, and containing accessory blood vessels for the 



PERICEMENTITIS. SO, 

further supply of the pulp. Later in life these are usually oblit- 
erated by the advancing calcification. That this is true, the clin- 
ical observation of almost any dentist of wide experience might 
establish. There are few such who have riot seen the whole apex 
of a tooth root denuded through some pathological process, with- 
out interference with the vitality of the pulp. Many have known 
instances in which, through diseased action or by accident, one 
side of the root of an anterior tooth, with the whole of the ap< x, 
was -completely denuded without any devitalization of the pulp. 
When this tissue has been restored by functional activity, the tooth 
was found as responsive to thermal changes as ever. The author 
has frequently had occasion to remove all the investing osseous 
tissue from a tooth root, save perhaps a comparatively small por- 
tion at one side, and that without final prejudice to its vitality. 
In some of these instances there could have been no vascular 
supply to the pulp, unless it was through some kind of Haversian 
canal penetrating the cementum and dentin upon a lateral aspect. 

It is well known to oral surgeons that resection of the 
inferior dental canal, with entire obliteration of the internal 
dental artery and nerve, does not in any way interfere 
with the vitality of the lower teeth, which the text-books 
frequently represent as receiving their vascular and ner- 
vous supply from that source. These considerations should 
materially modify our views of the pathology of the dental peri- 
cementum, and change some previous conceptions of its function 
and susceptibility to diseased action. In the light of these views, 
much that was before incomprehensible becomes plain and intelli- 
gible. We can understand why and how it is that the blood and 
nerve supply of the tooth is modified, and how it arises that the 
vessels of both are without the usual external muscular coats, and 
approach those of the brain in character. 

Having the important and compound functions of affording 
the pulp of the tooth its nerve and blood supply and giving nutri- 
tion to the cementum and bone, and being in close relation with 
the gum tissue, the pericementum is very likely to take upon itself 
an inflammatory condition. It serves as a cushion to break the 
Force exerted upon the tooth in occlusion, or from a blow or any 
other external violence. Hence it is liable to injuries and acci- 
dents. It is also very subjeel to infection by micro-organisms 
from a decomposing tooth pulp. This [asl is without doubt the 



90 ORAL PATHOLOGY AND PRACTICE. 

most fruitful source of inflammatory conditions, and such instances 
are constantly falling under the notice of the dentist and oral 
physician. Another common cause is the bad occlusion, or ab- 
sence of some of the teeth, which throws upon a few the work of 
many. 

Many practitioners have no clear conception of the difference 
between pericementitis and pulpitis, inasmuch as each produces 
a distinct odontalgia or toothache, which only close observation 
will distinguish from the other. And yet the two conditions have 
little in common except the pain, and that is not of the same 
character. It may be well to compare their pronounced symp- 
toms as an aid in diagnosis. 

Pulpitis. Pericementitis. 

The pain is of a sharp, lancinating The pain is dull, steady, boring, 

character, and in its earlier stages it throbbing in its character, and is not 

is distinctly paroxysmal. at all paroxysmal. 

The tooth is exquisitely sensitive There is no sensation to changes of 

to thermal changes: in its inceptive temperature, and neither cold nor 

state cold, and in its later condition hot applications materially affect it. 
heat, exacerbating it. 

There is no swelling of the tissue The tooth becomes exceedingly 

about the tooth, and no tenderness to sore, and the least pressure upon it 

pressure in ordinary cases. causes pain. In the later stages 

swelling is common. 

It is at times quite difficult to de- There is no trouble in deciding 

termine exactly which tooth is af- which tooth is the diseased one, the 

fected. the pain being fleeting in its pain being steady in degree and in 

nature. position, and the soreness readily 

locating it. 

The pain is apt to be worse upon The pain remains nearly constant 

going to bed, and excitement and without much reference to external 

fatigue increase it. conditions or circumstances. 

It is possible to bite upon the tooth The tooth is very sore to the 

without any special sensation, and to touch, any occlusion in mastication 

use it in mastication, if thermal ex- or ordinary shutting of the mouth 

tremes be avoided. giving pain, irrespective of thermal 

changes. 

The tooth is not elongated, nor The tooth is raised in its socket, 

does it strike first in occlusion. and strikes before any of the others 

occlude. 

Treatment of Pericementitis. 

The first care should be to give the offending tooth rest, hy 
preventing its occlusion. This may be done by placing gutta- 



PERICEMENTITIS. 91 

percha caps over other teeth, to prevent the striking of this. The 
cause should be determined, and if possible removed. If it be 
infection from a dead pulp, the chamber should be carefully- 
cleaned and sterilized, and an anodyne applied in the root channel. 
It may be advisable to seal up in it some of the essential oils, 
properly diluted, such as cassia or cloves, as an antiseptic. A 
counter-irritant should be applied over the apex of the affected 
tooth, for the same reason that it is used in pulpitis, and it is even 
more likely to be effectual. The same general remedies may be 
employed, such as saline cathartics, diaphoretics and nervous 
sedatives. Refrigerants are useful, and lumps of ice wrapped in 
muslin may be placed between the lip and the tooth. 

If these are not effectual, resolution may sometimes be in- 
duced by hot fomentation upon the face and neck. Prof. C. N. 
Johnson recommends that water as hot as can be borne be directed 
upon the part, with some force, for twenty or thirty minutes, to 
promote resolution. An acute pericementitis has also been 
readily aborted by the precisely opposite treatment of directing 
an ether or rhigolene spray upon the part until it has become 
bloodless. Both are useful, but are best adapted to different 
Stages of the disease. If infection is present Prof. A. W. Harlan 
recommends the administration of one-tenth of a grain of calcium 
sulphid every ten minutes for an hour, the interval then to be grad- 
ually increased. If there is a great degree of pain, the following 
may be administered: 

I? — Acetanilid., gr. viij; 

Syr. simp., -~>ij ; 

Spts. frumenti, 3ij. 

Sig. — One-half at 6 p.m., the remainder four hours later. 

The patient should be given a hot foot-bath, placed in bed 
and kept warm. If the inflammation is exceedingly acute, scari- 
fication (if the gums about the affected tooth may be resorted to. 
If there is gnat tension of the tissue, a sharp-pointed scalpel or 
bistoury may be used to cut through the gum tissue over the 
apex of the tooth, a little cocain having been previously applied, 
or the point of the instrument dipped in pure carbolic acid and 
applied to the surface until it lias become white, when it may be 
forced through the alveolar walls until the seat of inflammation 
is reached, thus removing the tension and giving immediate relief. 



92 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XXVI. 
ALVEOLAR ABSCESS. 

An Abscess is the formation of pus somewhere within the body, 
as the result of some local or circumscribed inflammation. An 
Alveolar Abscess is an infective inflammation within the alveolar 
walls. It may be the result of some foreign substance acting as 
an irritant, or some injury may have been the exciting cause. 
Either of these agencies may result in an inflammation so violent 
as to induce a breaking down of tissue, and infection with sup- 
purative organisms will induce the formation of pus, which 
reaches the surface by the route presenting the least resistance. 
An alveolar abscess does not, therefore, necessarily presuppose the 
death of the pulp. If the inflammation does not materially involve 
that tissue, or if the pericementum involved does not include that 
from which the blood supply of the tooth is derived, an alveolar 
abscess may be established without pulp devitalization. 

But such a condition is not that which is usually denominated 
alveolar abscess. The common acceptation of the term is that 
affection which is the result of inflammation and death of the 
pulp, its infection, and the consequent inflammation and infection 
of the pericementum from contiguity of tissues. If we take up 
the subject of the last chapter at the point of its closure, and 
suppose the pulp of a tooth to be devitalized as the result of stasis 
of the blood currents, with the consequent stoppage of all nutrition 
through a distinctive inflammation, the next inquiry will be 
concerning the final disposition of the devitalized pulp. 

If there is no source through which it can become infected 
with micro-organisms, it will probably become mummified and 
desiccated ; the moisture will be absorbed from it, and it • will 
assume the condition of dry gangrene, in which it will remain for 
an indefinite period without being the cause of any irritation what- 
ever. 

If, however, such a pulp chamber be opened without the 
strictest antiseptic precautions, perhaps years after the death of 
its contents, germs of infection will be carried in upon the non- 
sterilized instruments or admitted with a particle of saliva, and 
septic inflammation, with perhaps consequent alveolar abscess, will 
be the result. 



ALVEOLAR ABSCESS. 93 

The infection may arise from either one of two sources. If 
there is a cavity in the tooth that penetrates to the neighborhood 
of the pulp, the bacteria may there find entrance, and decomposing 
the pulp tissue by putrefaction they may cause the formation of 
offensive gases, which forcing their way through the foraminal 
openings will act as an irritant upon the pericementum, and 
induce an acute inflammation of that tissue. 

If there is no special cavity of decay in the tooth containing 
the recently devitalized pulp, through which infective organisms 
may find entrance, it may still become contaminated from some 
other center of infection that may exist in the body. The bacteria 
may be transported by the blood, or may in some other manner 
be carried within the body to the dead tissue, and in this manner 
form a source of contagion. By whatever method the pulp 
becomes inoculated with putrefactive or suppurative organisms, 
whether from external sources or by auto-infection, the result will 
be the same, — the formation of suppurative products and the infec- 
tion of the pericementum and other tissues in the neighborhood of 
the foraminal openings. Pus will then be formed and an abscess 
established. 

The condition that has existed up to this point is frequently 
denominated Incipient Alveolar Abscess. This simply implies the 
earlier stages of the destructive inflammation, before pus shall 
have been fully formed, during which period it may be possible to 
abort the abscess, or prevent the breaking down of tissue. 

A Blind Abscess is one in which there is a cavity of decay com- 
municating with the pulp chamber, and in which it is possible for the 
pus to be drained through the pulp canal. 

If the pus forces its way to the surface through the alveolar walls, 
it establishes a fistulous opening constituting a Discharging Abscess. 

The formation of an alveolar abscess depends upon infection 
by septic organisms. These are always a source of irritation, and 
induce inflammatory conditions. The pericementum about the 
foramina] opening of the root of a tooth being thus affected, there 
will ensue under the stress of the inflammatory conditions the 
phenomena described in the chapter (VI.) on General Inflamma- 
tion. There will be changes in the blood vessels of the vascular 
that will finally resull in diapedesis, or the pouring out of the 
plastic lymph. This will be infected by the organisms, and in- 



94 ORAL PATHOLOGY AND PRACTICE. 

stead of being either removed by resolution or built up by regular 
progressive metamorphosis, it will be broken down. The leuco- 
cytes, or white blood corpuscles that have thronged to the irritated 
neighborhood, will lose their vitality through the irritation and 
infection, and assume the character of pus corpuscles; the invest- 
ing tissue will be broken down and decomposed, thus forming a 
cavity about the foraminal opening: the water of the tissue and 
the serum of the blood will mingle with these, and the whole mass 
will be that fluid that forms the contents of the abscess cavity, 
and which is discharged from the fistulous opening as pus. 

There may be about the periphery of this pus cavity, 
when so formed through the breaking down of the tissue, 
a partial attempt on the part of nature to build the exudate 
into tissue. It may possess a kind of consistency, and this par- 
tially organized, partially desiccated plastic lymph will form a line 
of demarcation that will enclose the disturbed territory. Upon 
its periphery it will exhibit the characteristics described, but its 
center will be a collection of pus and disorganized lymph. If the 
tooth is now extracted, this mass may be found clinging to the 
root, the size of an ordinary pea, and when so removed with a 
deciduous tooth it has been mistaken by the unintelligent for the 
germ of a permanent tooth. It is only the plastic exudate that 
filled the cavity produced by the breaking down of the tissue, 
whose surface is desiccated or dried, while its interior is completely 
broken down. 

The infected point may not be at the foraminal apex of the 
tooth. 

The fact that the blood and nerve supply of the dental pulp 
are derived from the pericementum, and that channels analogous 
to the Haversian canals of bone may in comparatively young 
persons communicate with the pulp through the cementum and 
dentin at almost any point, naturally introduces another complica- 
tion in the proper treatment of so-called dead teeth. Xot infre- 
quently is an exceedingly sensitive point found somewhere along 
its course when a broach is passed into the pulp canal of a devital- 
ized tooth, and it may be that the oozing of blood and serum 
from such a point, even after the foramen has been stopped, will 
give great annoyance. This may be the mouth of one of these 
communicating blood channels, and it is easy to comprehend that 
the pericementum at the point at which this is given off may 



ALVEOLAR ABSCESS. 95 

readily become infected from a septic canal, and thus form a focus 
of inflammation and disorganization quite distinct from that about 
the usual foraminal opening. The latter may be thoroughly 
drained and completely sterilized without beneficial result, because 
it is reinfected from another opening in the pulp canal as fast as 
it is rendered innocuous. In teeth having more than one root, 
these collateral vascular branches are sometimes given off from 
the pericementum at the bifurcation, and at these points may be 
established a focus of infection and inflammation which it is 
difficult thoroughly to drain, and impossible entirely to disinfect 
and sterilize. 

Pus having once formed at any point about the periphery of 
a tooth, it becomes necessary for it to be evacuated, as it is essen- 
tially a foreign body possessing peculiarly irritating properties. 
It secures egress through the breaking down of the tissue that 
encompasses it. The pressure of the gases of putrefaction that 
are evolved, with that of the constantly increasing pus, causes 
resorption of the investing bone, while the inflammation and 
infection induce progressive decomposition, and thus an opening 
is made to the surface, the pus is evacuated and the acute symp- 
toms pass away. 

If no remedial measures are instituted, the sinus perhaps then 
closes up and the patient may fancy that a cure is established. 
But the pericementum at the infected point, and the tissues about 
it immediately involved, remain in a septic condition, and the 
efforts of nature to restore a true physiological condition are made 
nugatory by constant reinfection. An acute inflammatory stage 
again ensues, the plastic exudate is once more poured out, only 
to be reinfected, with a fresh breaking down into pus. The 
abscess "gathers" again, but this time, as the old sinus will not 
have been completely obliterated, there will be less resistance, and 
the pus will with decreased difficulty reach the surface. This 
process may be periodically repeated until a complete and con- 
tinually patulous sinus shall have been formed, when all acute 
symptoni> disappear and a chronic abscess is established, through 
the disorganization of the nutritive currents and the continuous 
effusion ami uninterrupted breaking down that ensue. This con- 
dition may persist until a cavity of considerable extent shall have 
been formed in the alveolus, or even in the body of the bone. 

The course of the pus in reaching the surface in the 



96 ORAL PATHOLOGY AND PRACTICE. 

usual forms of alveolar abscess is directly through the 
thin alveolar walls. This is the shortest route, and the one that 
ordinarily presents the least resistance. It may be, however, that 
special conditions point to a different road, and the pus may find 
some other cavity, and finally be discharged into the anterior or 
posterior nares, or into the maxillary sinus. Or, penetrating the 
alveolar walls, it may reach the fascia, and follow along the course 
of a muscle until it arrives at a point considerably distant. A 
discharging abscess under the chin, the direct result of a devital- 
ized inferior incisor tooth, has often puzzled the medical man, who 
never once thought that the dentist might give quick relief. Pus 
has been known to burrow along the fibers of the platysma- 
myoides muscle until it has reached the clavicle, or, penetrating 
the cervical fascia, finally strike the omo-hyoid and follow its 
course until it emerged at the point of the scapula. 

In some instances of rather indolent abscess, the pus makes 
its way through the alveolar walls until it reaches the periosteum 
of the bone, which it detaches, and spreading out beneath it com- 
pletely cuts off all periosteal nutrition, — a condition which, if not 
relieved, will result in osseous necrosis. This may be observed 
more frequently in the vault of the mouth, when the pus has 
penetrated the palatal process of the superior maxillary. The 
tough, fibrous character of the tissue immediately beneath the 
mucous membrane of the roof of the oral cavity presenting a great 
obstacle to the course of the pus, it not infrequently spreads over 
a considerable portion of one side of the vault. 

There are cases in which the pus burrows to some 
distance in the alveolus, establishing separate pockets 
which become distinct points of infection. In one such 
instance, from an infected point at the apex of a superior cuspid, 
which had a discharging sinus between that and the point of the 
lateral incisor, and which persistent treatment failed to cure, a 
secondary sinus was finally traced back to a point between the 
first and second premolars, or bicuspids, where was a second 
focus of infection, and from this another led yet farther, back of 
the roots of the second bicuspid, where there was a third pus 
chamber. It was not until all these were explored and sterilized 
that anything approaching a cure could be obtained. 

These secondary pockets, or foci of infection, whether upon 
the periphery of the tooth as the result of a former collateral 






SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. gj 

blood supply to the pulp, or existing as pockets within the alveolus 
in consequence of the burrowing of pus back into the bone, are 
especially perplexing to the practitioner, because he never knows 
when to expect them, and he has no early means of diagnosing 
the septic condition. After the proper disinfecting and sterilizing 
process has been resorted to in vain, it may be suspected that 
there are somewhere foci of infection that have not yet been 
reached by the remedies used. The continuation of the discharge 
of septic or sanious matter indicates that disinfection and anti- 
sepsis are not complete, and no entire cure may, under such condi- 
tions, be expected. 



CHAPTER XXVII. 



SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR 
ABSCESS. 

The objective as well as the subjective symptoms of Alveolar 
Abscess are sufficiently pronounced to obviate any mistake in 
diagnosis. That which is under special consideration, the result 
of the infection of the contents of a pulp chamber or canal, begins 
with a pericementitis that gradually increases in severity. The 
soreness is extreme; the tooth is materially lifted in its socket and 
becomes loose, with that peculiar feeling of non-support that 
indicates fluid at the extremity. This is the extravasated lymph 
and serum. Within a few hours there is the distinct febrile condi- 
tion, with its elevation of temperature, quickened pulse and suc- 
ceeding rigor, the septic fever that invariably indicates the forma- 
tion of pus and which is idiopathic. The red line or red blotches 
that arc characteristic of pericemental inflammation, and which 
arc peculiarly observable up to this point, now begin to fade away 
or to be succeeded by a deep red that is continuous with that of the 
neighboring tissues, and there is, in very acute cases, a tumor or 
distention of the alveolar walls. The pain, which is deep-seated, 
continuous, and of a boring character, is now intense, but there is 
little swelling of the soft tissues. 

The pus is burrowing its way toward the surface of the 
bone, and the pressure exerted by the confined matter is 
the source of the suffering. This continues until the .alveolar 
walls have been penetrated, and the pus escapes into the soft tis- 

8 



98 ORAL PATHOLOGY AND PRACTICE. 

sues. Great swelling now ensues, with amelioration of the pain, 
consequent on the escape of the confined fluid into the tissues that 
can yield to the pressure. Sometimes the infiltration of the tissues 
by the inflammatory products is so great as to close the eye and 
greatly distort the face. But, although. the appearance at this 
stage is much more serious and alarming than at previous ones, 
the pain and soreness are very much less, and the tension is re- 
lieved. Finally, there is "pointing," fluctuation may be distinctly 
detected beneath the finger, and the abscess is ready for the lancet. 
The general indications of the septic condition, the infection 
by pyogenic organisms and the formation of pus, will be as fol- 
lows: Anorexia, or loss of appetite; chills, or rigors of a more or 
less pronounced character; headaches, sharp and persistent; fever 
of a distinct type — septic fever; coated tongue; constipation; urine 
scanty and of a high color, and, finally, nervous disturbance, vary- 
ing from mere restlessness to violent delirium, according to the 
extent of the septic poisoning. If there are wounds through which 
the infection takes place, their edges will become red, swollen, 
tense, and angry in appearance. 

Treatment. 

Abortive measures should be instituted in the early stages of 
the pericemental inflammation. At this time counter-irritants, hot 
foot-baths, with laxatives and diaphoretic remedies, will be found 
useful. If a dead pulp is present, the pulp chamber should be 
opened under the strictest antiseptic precautions. 

The rubber-dam should be placed upon the tooth, to segre- 
gate it from the septic fluids of the mouth. The drill should be 
carefully sterilized, either by heat or by being allowed to remain a 
little time in some germicidal fluid. Debris should be removed 
from the cavity of decay, if such cavity exists, and it should be 
effectually sterilized with a bichlorid or some other energetic 
solution. As soon as the walls of the pulp chamber are punctured, 
the drill should be withdrawn and a sterilizing solution injected or 
carried in upon a pledget of cotton. The opening may now be 
enlarged, and the antiseptic or germicide carried to every possible 
point of the pulp cavity and canal. With a sterilized broach, all 
debris and remains of the decomposed pulp should be removed, and 
the canals made as clear of obstruction as possible. A few fibrils 



SYMPTOMATOLOGY AND TREATMENT OF ALVEOLAR ABSCESS. 99 

of cotton dipped in* some antiseptic, such as one of the essential 
oils, may be carried as near the apex of the root as possible, and 
sealed up in the cavity. If there is much pain, some anodyne, like 
tincture of opium, may be introduced into the canal on a very few 
fibers of cotton. 

This treatment, both local and general, should be continued 
until the inflammation with its soreness and pain shall have passed 
away, when operative measures for the preservation of the tooth 
and its protection from further attacks may be instituted. 

If from any reason the treatment shall prove ineffectual, the 
inflammation gradually becoming worse until the symptoms give 
indication that resolution cannot be expected, that degeneration 
has already commenced and infection has taken place, the treat- 
ment should be promptly changed, and suppuration encouraged. 
The general abortive measures must be abandoned, and the pus 
directed toward the surface. AVarm fomentations may be used, a 
cloth wrung out in hot water being applied to the face over the 
seat of trouble, and carefully covered, while the patient is kept 
warm. Indications of "pointing" must be carefully noted, and 
any tendency toward the exterior of the face should be re- 
pressed by painting it over with iodin solution, the application 
of cold, and other like measures. A poultice consisting of the 
fresh surface of a split fig, or raisin, that has been warmed and 
softened in hot water, should be placed over the alveolar wall 
opposite the root of the tooth or within the oral cavity where it is 
desired that the abscess shall point, and suppuration invited by 
that channel. This process should be hastened by every available 
means, that the formation of secondary pockets, with osteitis, or 
inflammation of the bone corpuscles, may be avoided. If the indi- 
cations are that the pus is burrowing in the wrong direction, thus 
threatening a prolongation of the condition, with the probable 
infiltration of the bone by septic products, the practitioner should 
lose no time in reaching the disturbed place with an instrument, 
and thus establishing a sinus at the proper point. 

The pus evacuated, the next step should be the disinfection of 
the whole territory. The pulp chamber should be opened and 
cleaned out, and the principal foramina! opening made patulous. 
About the extremity of the point of a suitable metal syringe, a rope 
made of a sufficient quantity of cotton fibers dipped in a chloro- 



IOO ORAL PATHOLOGY AND PRACTICE. 

percha solution may be wound, the point introduced into the cavity 
of decay, or that artificially made into the pulp chamber, and the 
cotton then closely packed around it. The barrel of the syringe 
filled with tepid water may now be attached and considerable force 
used until the stream entering at the pulp chamber emerges at the 
fistulous opening. The barrel of the syringe is now removed and 
filled with a solution of three per cent, pyrozone, or with electro- 
zone, and this is injected as a disinfectant. This is succeeded by 
a solution of bichlorid of mercury or some other effective germi- 
cide, and the cavity may be sealed up for a day or two. 

If at the end of sufficient time the indications warrant the 
belief that sterilization is complete, and that there are no secondary 
pockets of infection, the root may be permanently filled. If, how- 
ever, the septic condition continues in the least degree, or if there 
are signs of osteitis, the cavity should be opened and the sterilizing 
process repeated, or an antiseptic anodyne introduced still further 
to test the case. 

If the fistula is an old one and the abscess not of recent forma- 
tion, and especially if there are no acute symptoms, thus indicating 
a chronic condition, something more active should be introduced 
as an antiseptic. After the cleansing out of the pulp chamber and 
the root canal, the rubber-dam should be applied and a broach 
wound with cotton fibers dipped in a saturated solution of carbolic 
acid introduced, and the caustic antiseptic pumped through the 
tooth and along the sinus until it appears at the fistulous opening, 
where it may readily be detected by its turning the tissues white. 
This cauterizes the whole tract, inducing sloughing to a limited 
extent, and brings on acute symptoms, with effusion of plastic 
lymph, which in the thoroughly sterilized territory may be built 
into tissue by regular progressive metamorphosis. 

A solution of chlorid of zinc, five grains to the ounce, may be 
forced through with a syringe in these chronic cases, and this may 
bring about an acute condition and stimulate the indolent func- 
tional activity. Some operators proceed at once to fill after a 
single treatment such as has been indicated, but unless there are 
special reasons for haste it is better and safer to wait until it has 
been thoroughly demonstrated that there are no secondary pockets 
or foci of infection, and until the reparative process and the up- 
building of the waste territory has fairly commenced. This may 



SYMPTOMATOLOGY AND TREATMENT OF ALYEOLAR ABSCESS. IOI 

usually be determirted by the dryness of the root canal. To test 
this a fine broach should be thrust to the apex of the root, or as 
far as possible, quickly withdrawn and wiped upon a piece of 
rubber-dam. Any moisture will show at once, and will indicate 
that there is still a septic condition. 

There are instances in which it is impossible to force fluids 
through the foraminal opening or openings. This will more fre- 
quently be the case with the molar teeth, in which perhaps the 
infected point will be at the opening of one of the buccal roots, but 
it may occur with even the anterior teeth. Some operators insist 
that they are able to open the apices of such roots with a drill, but 
when it is recollected that seldom or never is the foraminal opening 
in a direct line with the canal, it will be found that none except 
men of the most phenomenal skill will be equal to this task. The 
average operator will hesitate before proceeding to such heroic 
measures. 

If it is impossible to pass a flexible broach through, the 
foraminal opening, or to establish communication between the out- 
side and the inside of the apex of the tooth, after the cleansing of 
the canal and the use of the general remedies recommended, the 
antiseptic may be introduced on a few fibers of cotton as near the 
apex as possible, and then sealed up within the tooth. The agent 
used should be one that is of as penetrating a nature as possible, 
and the experiments of Miller show that in this respect none 
possess any special advantage over pure carbolic acid. It should 
be changed as often as necessary, sometimes every hour, until the 
pulp canal is thoroughly and completely sterilized. Then by slow 
infiltration and absorption it will be carried beyond the apex of the 
tooth and sterilize the investing tissues. It may be necessary to 
continue such treatment for some time, especially when the inflam- 
mation is of an indolent, subacute character. But when the pro- 
cess is complete the sinus that may have existed will disappear, and 
all inllammatorv signs will depart. 

Sometimes treatment from the outside is the only resource. 
There are instances in which none of the usual curative measures 
are effectual. It is impossible to get through the Eoraminal open- 
ing, or perhaps the dentist has been too precipitate in filling the 
root and tooth with a material that it is difficult to remove. In 
Mich a case the seal of disturbance must be reached by establishing 
a sinus, or through thai already in existence. With a properly 



102 ORAL PATHOLOGY AXD PRACTICE. 

shaped inflexible probe it is usually possible to follow the course 
of a discharging canal to the apex of the root. A few fibers of 
cotton wet with a solution of cocain. or with carbolic acid, should 
first be introduced as an obtundent, and allowed to remain for a 
short time. The probe is then introduced, and the sinus carefully 
explored to its extremity. It will usually be found that the open- 
ing through the external alveolar wall is considerably above the 
fistulous opening, and its course may not be a direct one. But a 
little patience, with the knowledge obtained by some experience, 
will enable one to reach the apex of the root with comparative 
readiness, provided the lesion is not upon the palatal root of a 
superior molar. Having clearly outlined it, the opening may now 
be enlarged with a trephine or drill, if it is necessary, and the 
proper remedies carried to the diseased point. Deposits may be 
removed from the root, or its apical point amputated if necessary. 
All debris having been removed, and the parts carefully sterilized, 
granulation from the bottom will probably close up the opening. 
If it does not, the operator may be assured that there is dead or 
foreign matter in the cavity, or that it has not been effectually 
sterilized. 

In filling a sterilized devitalized root, it is not at all essential 
that the filling material shall be pushed farther than the junction 
of the dentin and cementum, at the point where the division of the 
canal into the foraminal delta begins. The broach will readily 
indicate this point, because it is sensitive beneath it. It is only the 
dentin that is devitalized, the cementum which forms the real apex 
of the root retaining its vitality. The delta or divided canal exists 
within the living cementum, and hence does not need to be filled. 
Dentists sometimes find this point exceedingly sensitive, and 
imagine that the pulp is not yet wholly devitalized. They perhaps 
introduce arsenical paste, and so do considerable injury. They 
should remember that the cementum at the apex is probably in an 
irritable condition, and needs an anodyne rather than a corrosive 
poison. 

There are instances in which the inflammation stops 
short of the formation of pus. The plastic exudate has been 
poured out, and has infiltrated the tissues and caused a distinct 
swelling. But the degenerative process has not begun, either 
because there is no septic infection or because sterilization has 
destroyed the organism. The inflammation is of a low, subacute 



DEPOSITS UPON THE TEETH. IO3 

character, and there is no pain or violence. The plastic exudate 
loses its usual consistency, either through the extraction of its 
watery part or because of some partial organization or other 
change, and has become indurated. The swelling is perhaps 
within the bone, and there is a distinct protrusion of the external 
wall. This condition may remain for an indefinite time, and it 
sometimes causes considerable deformity of the jaws. 

If this is the result of a pericemental inflammation at the apex 
of a devitalized tooth, resolution or reabsorption may usually be 
brought about by the injection through the tooth of tincture of 
iodin. If the foraminal apex is not open, cotton saturated with 
tincture of iodin may be sealed up in the tooth cavity, and changed 
as occasion requires, until the process is completed. If the offend- 
ing tooth is extracted, there will usually be immediate resolution, 
but this is not always advisable, and the iodin treatment may be 
resorted to for the slow relief of the indurated condition. 



CHAPTER XXVIII. 
DEPOSITS UPON THE TEETH. 

Under this head will be considered such superficial precipi- 
tates of inorganic matter as may induce pathological changes. 
They must be derived either from external sources or from some 
of the fluids of the mouth or the body. There are many forms of 
oral debris, the sediments of organic matter, deposits of focd, etc., 
that will not properly come within this category. The "white 
deposit," that cheesy deposition that is so often found encircling 
the cervical portion of the tooth and forming a narrow white line 
just at the gum margin, belongs to the latter class. It is composed 
of the debris of food that is partially fermented, micro-organisms, 
etc., and when it lias been allowed to remain for any length of time 
the tissue immediately beneath it will be found partially decalcified 
and softened. But the deposit itself is not of a calcareous nature, 
and is easily removed by the brush. 

The so-called "green stain" of childhood is wholly superficial. 
It is called "green" stain, although it may be dark, or bronze, or 
yellow in color. It has by some been considered a disease-pro- 
ducing kind of fungus, which penetrates the substance of the 
enamel, disintegrating it, and thus injuring the tooth. But if one 



104 ORAL PATHOLOGY AND PRACTICE. 

will immerse a tooth discolored by it in a ten per cent, solution of 
lactic acid he will in a few moments see the so-called Nasmyth's 
membrane separate from the tissue, and it will carry with it all the 
deposit, leaving the exterior white and uneroded. Sometimes it is 
found upon the surface of eroded, or even decayed enamel, but it 
can be removed in such a manner as clearly to indicate that it was 
deposited subsequent to the erosion, or caries. It has, then, no 
special pathological signification, except so far as it may be a 
symptom of some unhealthy condition of the fluids of the oral 
cavity. 

Salivary calculus is a deposit from the saliva. If one will 
through a tube breathe into a glass of lime-water, he will soon 
observe that the fluid becomes milky in appearance. If he will 
continue the process for a while, and then set the glass where it 
will be entirely undisturbed, he will after a time find deposited 
upon the bottom more or less of a fine amorphous powder. This 
is the calcium that was held in solution in the water, and which 
was thrown down as carbonate of lime. A few drops of hydro- 
chloric acid will clear up the fluid by again dissolving the pre- 
cipitate. 

It is in an analogous manner that the deposits of salivary 
calculus, which are composed of carbonate of lime, are formed. 
The CO„ of the breath uniting with the saliva which contains the 
calcareous matter, the latter is at once precipitated. Naturally it 
will be found in greater quantity near the mouths of the salivary 
ducts, and so the largest deposits are upon the inferior incisors 
opposite the mouths of Wharton's duct, and upon the superior 
molars opposite the discharging mouth of the duct of Steno. 

Sometimes this material is precipitated in great quantities, 
binding several teeth together in one mass. In some instances the 
utmost care of the patient will not enable him to keep the teeth 
entirely free from it. This will usually occur in the presence of an 
alkaline reaction. In mouths in which the oral fluids are acid it 
will commonly be continued in solution, and not precipitated on 
meeting the breath. When it is deposited in great quantities it is 
usually soft, of a creamy yellow color, and is easily removed. 
When it is deposited more slowly it has time for consolidation and 
becomes hard, and is usually stained a dark color by pigmentary 
matter from the oral cavity. 

It has no special pathological signification aside from the fact 



DEPOSITS UPON THE TEETH. IO5 

that it is a mechanical irritant, and keeps the teeth and month in 
a filthy condition by constantly acting as an absorbent, and as an 
obstruction against or under which food debris lodges. It should 
be carefully removed with instruments, the teeth polished, and, if 
necessary, the irritated gums touched with a stimulating astrin- 
gent. 

The so-called sanguinary or serumal calculus has another 
origin and is distinguished by separate characteristics. It is not 
found external to the margins of the gums, nor is it a precipitate 
from the oral fluids, — for no reference is here intended to the hard, 
black, smooth, supragingival, slow deposit which is but a modifica- 
tion of the usual form of calculus and is undoubtedly of salivary 
origin. The so-called serumal deposits are upon the side of a 
root that is not denuded when they are formed. They may be 
found when there is absolutely no break at the gingival border, 
and when consequently their precipitation from the oral fluids 
would be an utter impossibility. Instances of this are cited in the 
chapter on Pyorrhea. 

It is not deposited in a smooth, continuous, amorphous 
mass, as in the case of salivary calculus. It is found in 
dense, hard, closely attached, separate nodules, which may by 
further deposition become confluent. 

It cannot be scaled off cleanly and readily, as can the 
oral variety. It clings so closely as to make it necessary to chisel 
it away, in which process, unless great care is used, a scale of the 
tooth may be taken or a thin layer of the deposit left. It has not 
the same color as the salivary concretion, the latter, except when it 
has been discolored by subsequent pigmentary deposits or infil- 
trates, being of a dark yellow or yellowish white color. The 
serumal or sanguinary deposit is of an olive-black tint, with some- 
times an olive-greeri tinge. It is never identical, either in color or 
in manner of deposition, with salivary concretions. 

It is more distinctly irritating to the tissue than is the 
salivary deposit. Perhaps the 1. .ration of it within the tooth 
SOCkel may serve to account for the difference, hut aside from that 
there appears to he a rather distinctive irritation in its presence, not 
known in connection with the salivary deposit. 

Chemical analysis shows that there is a synthetic difference 
between tin- two, for, while calcium forms tin- base of both, the 
serumal contains certain elements not found in the other. The 



106 ORAL PATHOLOGY AND PRACTICE. 

analyses of it have not been sufficient in number or so exhaustive 
in character as to reveal all that may probably be learned from 
them. 

It is, then, accepted that this calculus is and must be derived 
from the blood, through the pericementum. Just what are the 
pathological changes accompanying its deposition has not yet been 
definitely determined. Whether it is a manifestation of the uric 
acid diathesis, and the concretions are the result of the lack of 
elimination of effete matter, as claimed by the advocates of that 
special origin of the pyorrheal condition, or whether it is a 
degenerative state of the pericemental membrane, the initiatory 
lesion being in that organ, has not yet been fully ascertained. 
One reason for supposing that it may not be due to a constitutional 
dyscrasia, that it is not a manifestation of a general disorder, but 
rather a symptom of a local degeneration or disturbance, is found 
in the fact that it is usually confined to one or two teeth. 

Certain it would seem to be that the trouble is not in the tooth 
itself, for the cementum does not appear to be affected in any way, 
further than secondarily through the mere mechanical separation 
from it of the pericementum. No morbid changes have been 
recorded as occurring in that membrane, except subsequent to the 
deposition of the calcific matter. Nor has any immediate connec- 
tion with other calculous deposits yet been traced. In gout and 
rheumatism there are enlargements of the joints, and sometimes 
intra-articular deposits of calcific matter. Concretions are found 
in the salivary and other ducts, but they seem to bear no relation to 
those of pericemental origin. Calculi are found in the bladder, the 
kidneys, and the prostate gland, but not coincidently with serumnal 
deposits upon the teeth; hence it would scarcely be inferred that 
they were part of an expression of the same pathological condi- 
tion. 

As far as our present knowledge goes, it must probably be 
accepted that these concretions are deposited by the pericementum 
upon the tooth, because of or through some aberrant or disturbed 
functional activity, the exact origin and progress of which has not 
yet been determined. 

The early presence of sanguinary calculus is not easily deter- 
mined. Salivary calculus exhibits itself unmistakably to the eye, 
and so there can be no error in its diagnosis; but such is not the 
case with the sanguinary concretion. It is hidden within the tooth 



PYORRHEA ALVEOLARIS. IO7 

socket at a point where examination is impossible. No prophy- 
lactic measures can therefore be employed. There may be a 
localized inflammation, with pustular swelling, but this comes too 
late for preventive measures. When a pocket reaching down to 
the deposit has been formed from the gingival margin, there is 
nothing left but its instrumental removal. 

There are instances in which pericemental irritation and sore- 
ness may, to the expert, give some warning of nodular formations. 
But these are too easily confounded with those which may be 
caused by hypercementosis, or by the presence of any other 
foreign substance, to afford any positive pathognomonic sign. 
When we comprehend the morbid changes of the disease better 
perhaps we will recognize premonitory indications, but, as it is, we 
must wait for its development. The usual revelation will come 
through the formation of the characteristic pockets beside the 
affected tooth, and the point of irritation, when near the apex of 
the root, may in some instances be detected by the localized 
inflammation and swelling. The treatment for the condition is 
laid down in the chapter on Pyorrhea Alveolaris. 



CHAPTER XXIX. 
PYORRHEA ALVEOLARIS. 



It is not a matter for boastfulness that so little should posi- 
tively be known concerning a disease that, after caries, is responsi- 
ble for the loss of more teeth than any other. It is but recently 
that any attention whatever has been paid to it. For many cen- 
turies it lias been cluing its destructive work without remark and 
without any attempt to determine its pathology. Not alone in man 
is it prevalent, but many animals suffer from its ravages. Do- 
mestic cats are especially liable to its attacks, while dogs are far 
from exempt. Horses sometimes suffer extremely from it, hut 
their teeth are not as often extruded and lust, because of the length 
and shape of the roots, which do nut end in a closed foraniinal 
opening. None of the teeth of persistent growth in the various 
orders of animals are materially affected by these disorders, so far 
as the author is aware. Bui he has in his possession tlie skull of 
an African gorilla, an animal that it has been found impossible to 



IOS URAL PATHOLOGY AND PRACTICE. 

keep in captivity, in which the characteristic appearance of this 
disease exists unmistakably. 

The condition has been known by various names. The late 
Dr. J. M. Riggs, of Hartford, Conn., was probably the first to call 
public attention to it, about the year 1850. For some time it was 
called from him "Riggs' Disease," but the impropriety of this being 
manifest, the term Pyorrhea Alveolaris was proposed, and has been 
generally accepted. Prof. G. V. Slack has denominated it "Phag- 
edenic Pericementitis," which is expressive of his very intelligent 
conception of its pathology. Dr. J. N. Farrar has proposed the 
name "Loculosis Alveolaris," from the fact that, very often at 
least, it has its origin in a kind of pocket beside the alveolus. 
Others, recognizing a communicable nature, have denominated it 
"Infectious Alveolitis." When its true nature and exact pathology 
are determined, a term that is descriptive of it will undoubtedly be 
universally accepted. In the meantime Pyorrhea Alveolaris, which 
signifies a discharge of pus from the alveoli, although somewhat in- 
definite, is as applicable as any. 

It has been intimated that the exact nature of the disorder 
has not yet been determined. At least no exposition of it has been 
generally accepted. That its seat is within the alveolar socket is 
easily demonstrated, and that either the tooth root or its investing 
membrane is an essential factor in its existence is quite plain, for 
extraction always affords a radical cure. Beyond this there is no 
admitted certainty concerning its etiology. Professor Black be- 
lieves the initial point to be in the pericementum. Others have 
held that it commences with a degenerative condition of the in- 
vesting margin of the alveolar process. Prof. W. D. Miller says 
that there are three active factors in its production; constitutional 
diathesis, local causes, and micro-organisms. 

Perhaps the hypothesis that has attracted the most attention 
up to this point is that so strenuously urged by Prof. C. N. Peirce, 
Prof. E. C. Kirk, and others, that it is but an expression of the uric 
acid diathesis, and is closely allied to gout, rheumatism, and allied 
disorders. It has been asserted, indeed, that it is always connected 
with them, either as a forerunner, a successor, or a substitute. It 
is urged that as urea is the effete product of the using up of tissue 
in functional activity, which the excretory organs should eliminate, 
its presence in the body is an indication of inactivity on their part. 
It is undoubtedly true that such effete matter must, from its very 



PYORRHEA ALYEOLARIS. IO9 

nature, by its continued presence excite a more profound influence 
than would any innoxious foreign substance. "We all know the 
extreme violence and general character of the protests of all the 
tissues of the body against its presence when manifested in uremic 
poisoning. 

The dense, hard, dark-colored nodules sometimes found upon 
the roots of teeth, and which are considered in Chapter XXYIIL, 
dealing with salivary and sanguinary calculi, it has been claimed 
are induced by and contain the urates of the blood, and are prime 
factors in inducing the pyorrheal condition. Could these asser- 
tions be substantiated as indisputable facts in all cases, they would 
be conclusive. But it is urged in answer that it is not positively 
demonstrated that the concretions referred to have their origin in 
the blood, that they are necessarily an expression of the uric acid 
diathesis, that they invariably contain any uremic salts, are at all 
essential to the pyorrheal condition, or are in any considerable 
proportion of instances the cause of it. They point to the fact that 
while they may be frequent or even usual concomitants, pyorrhea 
exists in its worst form without the presence of any such deposits, 
and quite unconnected with either gout or rheumatism. In the 
midst of this conflicting mass of evidence the only sure conclusion 
at which it is possible to arrive is that the subject has not yet been 
sufficiently considered, and that we have not verified ultimate 
facts. There is abundant cause for investigation and observation, 
and every real student should strive to add something to the knowl- 
edge of the subject, until enough has been learned to form a basis 
on which to build an hypothesis that shall be unassailable. Some 
patient investigator will yet solve the problem, as Miller gave us 
the solution of that of dental caries, which was for so long a time in 
the same unsatisfactory, unsettled, disputed condition. In the 
meantime it only remains practicable to present as clear an expo- 
sition as the present state of knowledge will permit. 



CHAPTER XXX. 

PYORRHEA ALVEOLARIS (Continued). 

True Pyorrhea Alveolaris should be a manifestation of some 
distinct, perhaps specific, pathological condition. The term itself, 
while expressive of our present knowledge, is too broad, covering 



IIO ORAL PATHOLOGY AND PRACTICE. 

altogether too much, for there are many exudations of pus from 
the alveolar walls that are easily explainable, and of very simple 
origin. But until its exact nature is distinctly marked out, and all 
its phenomena comprehended, we must recognize at least three 
separate pathological degenerations that are covered by the term, 
and which without doubt are often confounded with each other. 

The first of these will be entirely local in its character. 
It will have its origin in an easily comprehensible cause — local irri- 
tation. 

The second will have its etiology in deposits of a hard, 
nodular character upon the roots of the teeth. It will be 
distinguished by the formation of distinct pockets within the 
alveolus. 

The third will give evidence of some distinct cachectic 
condition or dyscrasia. It will present phenomena that are 
peculiar to itself, and will be without either of the two previously 
named factors. 

The first condition is a localized gingivitis, with possible alveo- 
lar caries, or a slow solution of the alveolar edges. It is charac- 
terized by inflamed, turgid gums, which are everted at the cervix. 
There will probably be a degenerate mucous secretion of a viscid 
character and acid in reaction. The gum is not adherent to the 
teeth, and the point of an instrument can be passed between them. 
Instead of the hard, dense appearance that the gingivae usually pre- 
sent, they bleed at the slightest touch. A little pus can be forced out 
from between the gum and tooth, but it is small in quantity and 
thick in consistency. The patient gives the teeth but little care, 
and they usually present anything but a healthy appearance. The 
redness is principally confined to the gum margin, and there are 
few or none of the peculiar red blotches higher up that are indica- 
tive of pericemental inflammation. An explorer cannot be passed 
up far beneath the gum, and, with the exception of roughened 
edges, the alveolar process is perfect. 

The prognosis of this condition is always good. The 
first care should be thoroughly to clean the teeth, and to remove 
from about their necks, especially from beneath the gums, any 
foreign substances that may have accumulated. Not infrequently 
delicate rings of salivary calculus will encircle them close up to the 
alveolar border. All traces of this must be removed, and the necks 
of the teeth be carefully polished. Sometimes foreign substances, 



PYORRHEA ALVEOLARIS. Ill 

like slivers from wooden toothpicks, or spiculae of bone from the 
food, will be found driven beneath the gums, and these will be the 
source of irritation. After careful cleaning the gums should be 
well rubbed, and a soft tooth-brush, with some antiseptic wash,' 
should be prescribed. Listerine is good for this purpose, or any of 
the pleasant essential oils, largely diluted. Care and cleanliness, 
with the removal of every foreign substance, will be sufficient to 
produce a cure, for the condition was only the result of a lack of 
attention, and the irritating presence of foreign substances. 

The second condition is one of greater moment. It is charac- 
terized by the presence of deep pockets in the alveolus, at one side 
of the anterior teeth, or perhaps between the roots of the premolars 
or molars. There may be. little of the turgidity or tumefaction 
described in the previous paragraph, but an exploration with an 
instrument will detect a resorption of the alveolar walls of the tooth 
socket, and pus may be forced out. Often the tooth, especially if 
it is one of the six anterior ones, will commence an inclination 
away from its neighbor. It loses its upright position, perhaps falls 
out of the line of the arch, and the previous regularity of a well- 
ordered dentition becomes sadly broken. The affected tooth is 
always deflected from the side on which is the pocket, and not 
toward it. A more careful exploration of this pocket will usually 
detect, well up toward the apex, or along the body of the root, 
dense, hard, gritty nodules, that are closely attached to the side of 
the root, enveloping more or less of the surface that has been 
denuded of its pericemental membrane, but which is yet covered by 
the gum. These are the sanguinary deposits described in the 
opening of this chapter. 

\\ 1] ether these are the cause or the result of the diseased con- 
dition has formed a fruitful subject of discussion among etiologists. 
Those who believe them to be deposits from the fluids of the mouth 
insist that there must be some connecting opening between them 
and the oral cavity, along the side of the tooth. But competent 
observers have described instances in which there absolutely was 
none. One such case fell within the observation of the author. 
I [is associate in practice found opposite the lower third of the root 
of a lower central incisor, in the mouth of a woman who took excel- 
lent care of her teeth, a peculiar swelling that had somewhat the 
appearance of incipient alveolar abscess, hut which had none of the 
other symptoms that attend that disorder. Tin- author counseled 



112 ORAL PATHOLOGY AND PRACTICE. 

pursuance of the expectant plan, and waiting for developments. 
In a very few days pus gathered in a comparatively small amount, 
and was discharged. The opening was enlarged, and opposite it 
were the characteristic nodules of the so-called sanguinary, or 
serumal calculus. Yet the gingivae were absolutely unbroken, 
and there was not the slightest indication of irritation about the 
neck of the tooth. The nodules were carefully removed, the open- 
ing antiseptically dressed, when it healed, leaving no sign whatever 
of the lesion, nor has any since appeared. 

It must be accepted that, in some instances at least, the serumal 
nodules are the first indications of the disturbance. Whether 
these are the result of any special diathesis we need not now in- 
quire. YVe know that they are specially irritative in their nature. 
If they form the initial point of the disorder, the subsequent patho- 
logical changes may be easily comprehended. They lift the peri- 
cementum from the tooth, and by their presence originate the 
breaking down of tissue. Infection follows, and the pus forces its 
way to the gingival margin, thus making an opening into the 
pocket already formed. Or perhaps the pocket is completed by the 
continuation of the deposits to the gum margin, the infection being 
subsequent to this. Perhaps, in a proportion of the cases, the 
deposition of the calculus commences at the neck of the tooth and 
proceeds toward the apex, forming the pocket from the margin 
instead of from the interior of the alveolar socket. 

The prognosis of this condition depends upon the 
ability completely to remove the deposits, and upon the 
general tone of the system, or its ability to bring about a 
restoration of the lost tissue. The first remedial measure is 
thoroughly to cleanse the teeth and pockets. This must be the 
work of time and patience. If the disease has extended so far as 
to induce much soreness and looseness of the tooth, it cannot be 
accomplished without considerable pain. So dense and closely 
attached is the deposit in many cases that a sharp, stiff chisel, with 
considerable force, is demanded. The drawing motion of a scraper 
is insufficient. Only the thin edge of a chisel will reach its last 
particle, which may lie just at the point of union of pericementum 
and tooth. 

There is no chemical agent that can be depended upon 
to dissolve the deposits away without injury to the sur- 
rounding bone and tooth. The usual mineral acids attack the 



PYORRHEA ALVEOLARIS. II3 

latter quite as readily as the concretion. Trichloracetic acid has 
been found of benefit in softening it, so that it may more readily 
be removed with instruments. This may' be used in from twenty to 
fifty per cent, aqueous solution, the exact strength to be determined 
by trial. It should be carried to the extremities of the pocket on a 
narrow, wedge-shaped piece of orange wood that has been dipped 
in the solution, and by a pumping motion continued for a sufficient 
length of time every nodule may be saturated with it. Or it may 
be carried upon a rope consisting of a few fibers of cotton wet with 
the acid. Dr. W. J. Younger, who has made a specialty of the 
treatment of pyorrhea, uses and recommends lactic acid for the 
same purpose, and claims that it is of special therapeutic value in 
this disease. 

It may be necessary to repeat the operation more than once, 
carefully chiseling or scraping off all that is practicable each 
time, until the root is clean and polished. The pockets should be 
washed out and treated antiseptically. Finally, when all the deposits 
are removed, a weak solution of chlorid of zinc may be injected as 
a stimulating astringent. It may be necessary to freshen the 
alveolar edges with a hoe excavator, or a safe bur, to induce new 
granulations. When there has been an effusion of coagulable 
lymph it should be protected, and not carelessly wiped or washed 
away. To this end it is necessary to know when to stop active 
surgical or operative measures, and to leave the rest to the vis 
medicatrix natures. Pursuing this course, the author has had the 
great satisfaction of seeing pockets that reached almost or quite 
to the apex of the root, and into which a considerable quantity of 
cotton could be packed, completely healed and filled with a new 
growth of bone through the action of a newly-formed perice- 
mentum. 

The prognosis of the third condition is almost inva- 
riably bad. It seems to be connected with some vicious consti- 
tutional condition that prevents eradication of the disease. There 
is frequently very little- if any gingival inflammation. There is no 
thickening or tumefaction, and but little redness of the gums. Per- 
haps they may even be abnormally pale and bloodless. There are 
none of the pockets of the preceding conditions, but there is a 
steady wasting of the alveolus, a continual recession of the gums, 
with a constant and sometimes profuse discharge of pus from the 
sockets of the teeth. In the pocket form a single tooth may be 

9 



114 ORAL PATHOLOGY AND PRACTICE. 

affected, but in this state it usually spreads from tooth to tooth, 
until all or nearly all of either or both jaws become affected. There 
is no special pain, or any great degree of soreness until the later 
stages are reached, when the loss of the teeth seems imminent, and 
when the destruction of tissue goes on with such rapidity that it 
almost assumes the acuteness of alveolar abscess. 

There may be no deposits of any kind. The condition may 
occur in the mouths of those who are fastidious in the care of their 
teeth, and who regard its insidious but sure advances with horror. 
They fight it with every weapon at command. The}- may retard it 
for years, but it is seldom that it is entirely eradicated. The author 
has under his care instances in which it manifested itself twenty- 
five years ago, and though it has been kept in check, sometimes 
by the most radical measures, it still crops out occasionally, and 
he and his patient have never been long entirely separated. 

When a radical cure of this form of the disease has been 
effected, it has usually been because of some constitutional change 
in the general tone of the sufferer. It has ever been prone to attack 
anemic and atonic persons, though it is not confined to them, and 
when it has been eradicated it has been accompanied by a com- 
plete change in the bodily health of the patient, and a return to a 
tonic state. 

The treatment of this special condition must, to a con- 
siderable degree, be general in its nature. When tonics are 
required they should be administered. If there is any distinct 
diathesis with which it may be connected, that should be attended 
to. Antiseptics must be constantly used, and the mouth kept as 
free from putrefaction as possible. Stimulating, astringent mouth- 
washes should be frequently employed, and every hygienic pre- 
caution exhausted. The space between the gum and the tooth 
should be kept clean, and whenever necessary it should be wiped 
out with some mild cauterant, like lactic or trichloracetic acid. 
Massage should frequently be employed by rubbing the gum with 
the ball of the finger, using considerable force. The tooth-brush 
should not be too harsh, and washes rather than powders should be 
employed with it. 

In some instances the author has seen what he thought to be 
good results following the use of anti-gout and rheumatic remedies. 
The employment of lithia in some form, or of salicylic acid, has 
been especially recommended. Dr. E. C. Kirk has reported excel- 



FACIAL NEURALGIAS. II5 

lent results from a persistent use of lithium bitartrate, in the form 
of tablets. 

If a tooth becomes very loose through destruction of the 
alveolar socket it is usually best to remove it, but when it is the 
result of an acute inflammatory stage, it may be held firmly for a 
time by weaving a ligature about it and the adjoining teeth. 
Sometimes there may be a decided amelioration following the 
burring away of the diseased edges of the alveolar process, with the 
use of antiseptics and stimulating astringents, but too often this is 
not permanent. Very little dependence can be placed upon the 
many specific methods and remedies offered by those who claim to 
cure the incurable. The best results will be attained by the practi- 
tioner who, to general medical intelligence, adds the most faithful, 
diligent, painstaking care in the line of treatment adopted. Of 
course, when the whole or nearly the whole alveolar socket of a 
tooth has been lost, further temporizing methods are useless. 



CHAPTER XXXI. 
FACIAL NEURALGIAS. 



Neuralgias are organic affections of a nerve, and may be either 
constitutional, functional, or local. Those first named arise from 
cachexia, and are associated with a constitutional diathesis. The 
second are due to disturbed nutrition and the consequent lack 
of tone, while the third originate in a direct lesion, or in some 
local irritation. An instance of the first is the general neuralgia of 
gout; of the second, that of miasmatic affections; while the third 
may be found in prolonged dental disturbances. Strictly speaking. 
any pain is a neuralgia, but the usual signification is confined to an 
affection of a nerve trunk, as distinguished from that caused by the 
irritation of a terminal filament. The continued pain arising from 
a neuromatous tumor is an instance of neuralgia from a true lesion 
of a nerve trunk. 

True neuralgias are principally confined to the afferent nerves, 
but they may be reflex and hence have their origin in the efferent 
or motor nerves. The facial neuralgias that form the majority of 
the affections presented to the notice of the dentist are manifested 
in the trigeminus, and their most frequent cause i- diseased teeth. 



Il6 ORAL PATHOLOGY AND PRACTICE. 

The irritation from caries may be so severe, or so long continued, 
that the trunk of the nerve is affected and its function so modified 
'that it remains in a permanently irritable condition. 

The diagnosis of this disorder is not always easy. That is, it is 
sometimes difficult to determine whether the pain arises from a 
mere local irritant, like the inflamed pulp of a tooth, or if it is a true 
degeneration or functional disturbance of the nerve tissue. In 
facial neuralgia the first thing to do is to look for the cause, and to 
determine whether it may not be mere odontalgia, or toothache. 
To this end the most minute examination of the teeth upon the 
affected side should be made. Cavities may exist beneath the gums 
which only the most careful search will reveal. Every test for in- 
flamed and irritated pulps should be tried, and in the great majority 
of instances the suspected neuralgia will be found to be mere tooth- 
ache. 

Every local cause having been excluded, the general bodily 
condition should be noted. If any distinct diathesis exists, like 
that of gout, rheumatism, syphilis, malaria, or catarrh, its possible 
connection with the disturbed neural currents should be looked for. 
If there is a state of anemia, or lack of nutrition, here may be its 
origin. The starved nerves are crying for the sustenance that 
they lack. 

All these sources excluded, a neuroma, or some other disor- 
ganization of the nerve tissue itself may be suspected. When 
this is the case and a true neuralgia is indicated, more minute in- 
quiries should be made as to the character of the subjective symp- 
toms. 

If neuralgic, the pain will be unilateral. Though not 
local, it will affect but one side, for bilateral disorders of this kind 
are something more than rare. 

The pain will usually follow the course of the trunk of 
the diseased nerve. That is, it may be recognized at different 
points in the route. 

It will be sudden in its attack. Its onset will not be a 
gradual approach, increasing in intensity until the climax is 
reached and then subsiding by degrees, but, from entire ease, in- 
stantly the victim is in the throes of the most agonizing torture. 

It will be of a darting, stabbing, boring character. It 
is not the steady, dull, throbbing, continuous pressure of a pus- 
gathering. 



FACIAL NEURALGIAS. 117 

It will be markedly intermittent. There will be intervals 
of complete immunity of greater or less length succeeded by 
paroxysms that will end as suddenly as they begin. There may 
or may not be regularity in these attacks. 

In the earlier stages there is usually an increase in 
severity with each paroxysm, to be succeeded by decreas- 
ing violence. While the invasions are sudden in their attack and 
subsidence, there is a true paroxysmal character to their recur- 
rence, each one becoming more severe until the climax is reached, 
when the abatement will be as gradual. 

There is no functional disturbance connected with the 
attacks. The pulse will not be accelerated, nor will the tempera- 
ture rise. There is no fever or other general disturbance. This is 
an important pathognomonic symptom. 

In some instances, especially in cases of long stand- 
ing, there will be soreness' along the track of the affected 
nerve. This may be especially marked at the foramen of exit. 
Anesthetic spots in the tissues supplied by the disordered nerve 
may assist in the diagnosis. 

Reflex symptoms in communicating nerves may be ex- 
hibited. There may be spasms and muscular twitchings. Tears 
may flow, the effect of reflex irritation, or salivary secretions may 
be markedly increased. 

Fatigue and depressing influences bring on attacks, or 
exacerbate them. The receipt of distressing news will be likely 
to provoke an attack. Sleeplessness or any unusually prolonged 
exertion will he likely to be followed by paroxysms. 

The clinical history is usually quite distinct and 
marked. Neurotic persons, and those with an unbalanced nerv- 
ous organization, are especially liable to attacks. Hence the 
neuralgias are frequently closely related to hysteria, migraine, sick- 
headache, hypochondria, paralysis, catalepsy, epilepsy, and other 
nervous and convulsive disorders. Clavus hystericus is hut 
another special form of it. 

It usually accompanies or indicates an atonic, debili- 
tated condition. It is sometimes among the sequelae of a long- 
continued Fever or other exhausting disease. 

It is especially liable to attack those who are suffering 
from malaria or miasmatic fevers. In such instances it some- 
times assumes tin- form of "hn>w ague." 



116 ORAL PATHOLOGY AND PRACTICE. 

The gouty and rheumatic diathesis seems especially- 
provocative of different forms of neuralgia. Among these, 
sympathetic affections of the trigeminus, or fifth cranial pair, are 
not uncommon. Indeed, sympathetic pains along the course of 
communicating branches or nerves, or through those but second- 
arily connected by different ganglia, would naturally be anticipated 
from the very nature of the disorder. It could not well be other- 
wise than that reflected pain would be felt in perhaps distant tissues 
or organs. These may not be of a severe character, and they will 
probably be felt at the outset, or more likely still at the close, of a 
paroxysm. Yet their existence may be an important part of the 
clinical history, and should be carefully sought out. 

Treatment. 

A real neuralgia having been clearly diagnosed, the first thing 
will be to determine its cause and to remove it. If there is any 
local source of irritation it must be remedied. 

The hygiene of neuralgic patients should be carefully looked 
to. They must be guarded from sudden changes of temperature, 
draughts of cold air, etc. All sanitary precautions must be 
adopted, and if the patient suffers from malaria removal from the 
miasmatic influence is the first consideration. 

Plenty of out-door exercise must be urged, with a liberal, 
rather stimulating diet. Extreme fatigue should be guarded 
against, and bodily and mental rest is important. 

If there is a constitutional or general functional dyscrasia, it 
must be relieved. Nervous sedatives may be prescribed, and gen- 
eral quiet insisted upon. 

Potassium bromid, ten grains in water, from two to ten times 
per day, will be found useful, or tincture of valerian and gentian, 
equal parts in teaspoonful doses. . During the paroxysm, digitalis, 
or veratrum viride in five-drop doses may be given, and aromatic 
spirits of ammonia in fifty-drop doses will be found useful. 

If there is a gouty diathesis, wine of colchicum in small doses, 
frequently repeated if necessary, should be prescribed. 

Muriate of ammonia fumes, arising from the burning of the 
salt upon a hot iron in the room, sometimes give gradual relief. 

If the neuralgia is of miasmatic origin, from three to ten grains 
of quinine should be administered, or Fowler's solution of arsenic 
and potash in ten-drop doses, two or three times per day. 



FACIAL PARALYSIS. 119 

Hot moist applications to the affected parts are very useful, 
and massage sometimes gives very ready relief, although there are 
instances in which it will be found exacerbating. It must be 
gentle, and not too long continued at first. 

If the paroxysms are very violent, it may be necessary to allow 
the patient to inhale the vapor of ether or chloroform for a short 
time; of course, not to the point of entire narcosis. 

If none of the usual remedies are effective, and if the 
paroxysms are violent, resection of the affected nerve may be 
necessary. This will, with comparative frequency, be called for in 
neuralgia, especially in that of the inferior maxillary nerve. Pro- 
fessor Brophy, of Chicago, has greatly simplified this operation, 
and by his method it no longer presents any formidable difficulties. 
His resections of the infra-orbital from tne oral cavity also relieves 
that operation from many complications. 



CHAPTER XXXII. 

FACIAL PARALYSIS. 



In its etiology, this affection is closely connected with facial 
neuralgia, but differs from it in being the effect of lack of nerve 
nutrition; the neuralgias are usually the result of over-stimulation 
of the nerve. It arises from disordered nerve function, and its 
treatment very properly falls within the province of the oral physi- 
cian, inasmuch as not infrequently it is the result of some oral 
lesion. 

Facial paralysis is the complete inhibition of efferent neural 
currents in the tissues affected, with usually a local anesthesia, more 
or less complete. It may be traumatic or idiopathic in its origin. 
If the former, ther will be no difficulty in determining the fact, 
while in the latter case its source will be more obscure. It may be 
complete or incomplete. It is complete when there is a total loss, 
and incomplete when there is more or less diminution of function 
in the nerves. It is general when there is loss of power in both 
the upper and lower extremities, and local when it is limited in the 
number of muscles affected. Facial paralysis is local in its charac- 
ter, and as seen in oral practice it is usually but partial. 

Paralysis of sensation may be either loss of tactile sense — in- 



120 ORAL PATHOLOGY AND PRACTICE. 

ability to receive impressions from external contact — or immunity 
to painful sensations. Thus the skin and the mucous membrane 
of the mouth are endowed with both kinds of sensibility. The 
capacity of these tissues to receive painful impressions may be 
quite impaired, or even lost, while the tactile or feeling response 
to external agents remains. But in these instances the impression 
made by ice, or a hot iron, will not materially differ from that 
derived from a piece of wood. Paralysis of the tactile sense is com- 
monly called anesthesia, while that of the sense of pain is denomi- 
nated analgesia. Reflex paralysis is a term that has been applied 
to cases in which a paralyzed condition of certain parts is attributed 
either to a wound or shock received from other and more or less 
remote parts, or to a local disease situated elsewhere than in the 
paralyzed region. Dr. Brown-Sequard supposed this to be induced 
through shock to the vaso-motor nerves, thus interfering with the 
nutrition of the nerve centers. 

The instances of paralysis that are of the greatest interest to the 
dentist are those of the fifth and the seventh pair of cranial nerves. 
The fifth, or trifacial, is the great sensory nerve of the head and 
face and the motor nerve of the muscles of mastication, while the 
seventh is the motor nerve of the muscles of expression. Com- 
plete paralysis of the fifth nerve results in the loss of sensibility of 
one side of the face, of the mucous membrane of the mouth, the 
conjunctival membrane, the anterior portions of the tongue, with 
the muscles of mastication upon the affected side. The external 
manifestations are not so pronounced as in paralysis of the seventh 
nerve, because the resulting deformity is not so great. There is a 
loss of the special sense of taste, and sensation is absent. But if 
the affection is unilateral, mastication may be carried on by the use 
of the muscles upon the sound side. The tongue and buccal tissues 
upon the paralyzed side are too frequently bitten and lacerated in 
the act of taking food, sometimes seriously, because the muscles 
are unable to keep themselves from getting between the teeth, and 
sensation being gone the patient is unaware of the injuries that are 
being received. Such paralysis may be induced by long exposure 
of the face to cold or a keen wind. 

Paralysis of the seventh cranial nerve is perhaps not so com- 
mon as that of the fifth, but it is much more readily observed, as it 
results in serious deformity. With the loss of function in the nerve 
all expression in the affected side is lost. In speaking or smiling 



FACIAL PARALYSIS. 121 

the mouth is drawn toward the sound side through the loss of con- 
tractile power in the muscles of the affected side. The contractility 
of the orbicularis oculi being absent, the patient is unable to close 
the eye or to wink. The secretions of the lacrymal gland are not 
diffused over the conjunctiva owing to the loss of function in the 
orbicularis, and there is a more or less constant overflow of tears 
upon the cheek. The saliva dribbles from the angle of the mouth, 
and the pronunciation of certain letters of the alphabet is interfered 
with. 

Paralysis of the seventh is perhaps most often caused by intra- 
cranial disease. These cases will properly fall within the province 
of the general practitioner. But it may be the result of injury. 
The extraction of a considerable number of teeth at one time may 
produce a shock that will cause spasms of the muscles of mastica- 
tion, or even inhibition of function and paralysis, with jaw drop. 
The spasm may be clonic (paroxysmal) or tonic (continuous). 

The symptoms are too pronounced to be mistaken. There will 
be a drawing of the muscles of the face, due to their entire relaxa- 
tion, with a loss of mobility. The eye remains staringly open, and 
a smile is observable on one side alone. All expression upon the 
affected side is lost and the muscles are in a state of tonic relaxa- 
tion. This will be observed by the operator before the patient 
becomes aware of the lesion. If it is of a clonic character he may 
by gentle manipulation of the tissues relieve the spasm or tem- 
porary paralysis, and within a few moments have the satisfaction of 
seeing the muscles regain their tone. Of course he will remove 
tin- hand-glass from the reach of the patient to prevent the unneces- 
sary alarm and nervousness which discovery would cause, and 
which would only tend to aggravate the condition. Should the 
injury be more lasting in its character and assume a tonic form, the 
dmtist should explain to the patient the probably temporary nature 
of the lesion and commence the proper treatment for relief of the 
condition. 

One of the most effectual remedies for this condition is 
electricity. The faradic or induced current should ordinarily be 
used, and it must be gentle at the OUtsel : nor should it be continued 
too long. The cathode or negative pole should be placed over the 
cerebellum, and the anode or positive electrode carried gently over 
the points of distribution of the affected nerve. I >ccasionally the 
pole may he changed, and if it is desired to stimulate the facial 



122 ORAL PATHOLOGY AND PRACTICE. 

nerve alone, the stationary electrode may be placed immediately in 
front of the external auditory meatus, while the other is moved 
successively over the various terminal branches. This treatment, 
if found beneficial, may be repeated every day, provided the cur- 
rent is not too strong and not too long continued. At the outset 
it should not be used so often. 

If the disorder has its seat in the ganglia, the magneto-electric 
interrupted current may sometimes be used with good effect, but it 
should be employed with caution, because it may still further tend 
to the inhibition of the neural currents in exhausted trunks or 
branches. 

Massage of paralytic muscles, if mild and properly 
applied, will be of great benefit in many cases. The facial 
muscles may be gently manipulated with the balls of the fingers, 
and rubbed in the direction of their fibers with the palm of the 
hand. 

The hygienic condition must, of course, be carefully looked 
after, and out-of-door exercise with nourishing food directed. 
Vegetable tonics may be prescribed if indicated, and quiet and rest 
ordered. If the paralysis is the result of any trauma, such as the 
extraction of teeth, the wounds must be carefully examined to see 
if there are any loose fragments of alveolus or bone left, and all 
possibly irritating projections and spiculae should be removed. An 
aseptic condition must be maintained, and soothing applications 
applied. With these precautions, unless the lesion is very great, a 
gradual return of functional activity may be anticipated. 



CHAPTER XXXIII. 

SYMPATHETIC DISTURBANCES. 

The nervous system of the body holds all the various organs and 
tissues in correlation with each other, and secures harmonious 
functional action between them. Every organ works, not for itself, 
but for all the rest. There is but one heart to carry on the vascular 
circulation for all the tissues, but one digestive tract to provide 
nutrition for all, and but one pulmonary organ to furnish the neces- 
sary supply of oxygen. Hence the mutual interdependence is 
complete, and no tissue or organ can be properly studied aside 



SYMPATHETIC DISTURBANCES. I23 

from its relation to the others. No oral physician, or dentist, is 
equipped for the practice of his specialty until he can show that 
he has made himself acquainted with the functions of other organs, 
and has learned their possible reflex agency upon those with whose 
care he is especially charged. A fair knowledge of the anatomy 
and the physiological function of every tissue in the body is essen- 
tial to the dentist as well as to the general practitioner, and with- 
out the basal facts upon which all curative measures must be 
founded he is as unfitted for his vocation as would be any other 
man who professes to practice any branch of the healing art. Any 
disordered condition of one organ affects to a greater or less degree 
all the others. The sympathy may not be as active in one case as 
in some others, but it is as certain. The dependence of one tissue 
or organ upon another may not be as complete or entire as that of 
others, or as may be the reciprocal reliance, but it surely exists. 
Proper functional activity of the brain may for some years be 
more disturbed by indigestion than would ensue to the stomach if 
the converse were the case, but no physiologist would assert that 
digestion could be properly and fully performed in cerebral conges- 
tion. The gravid uterus of the female will be more deranged by 
toothache than the teeth will be disturbed by metritis, but each 
reacts upon the other to the extent of its susceptibility, and their 
mutual relations cannot be lost to sight. 

The organs disturbed by diseases of the teeth and the oral 
tissues will be those to which they bear the closest relation. It is 
well known that the teeth sympathize with each other to such an 
extent that it is sometimes difficult to determine which one, and 
sometimes which jaw, is affected. Otitis media may exhibit itself 
as toothache, while on the other hand pains in the middle ear are 
very often mere reflexes of odontalgia. The eye sympathizes with 
the teeth to such an extent as sometimes to exhibit a profuse 
lacrymal discharge as the accompaniment of toothache, and alveo- 
lar abscess may be diagnosed by the condition of the pulse. The 
otologist especially should be on good terms with the dentist, for 
mutual consultation is frequently desirable, owing to the intimate 
relations of the organs concerned. 

But that which most interests both practitioner and 
patient is the possible complications of pregnancy. Women 
have long been taught that the relations between the teeth and 
the impregnated uterus are so intimate that each must suffer from 



124 ORAL PATHOLOGY AND PRACTICE. 

the faults of the other. "For every child a tooth," was a proverb 
long before the period of modern dentistry. That extraction is 
very liable to be followed by premature delivery is a part of the 
creed of every expectant mother. The impression resting in the 
minds of too many dentists that temporary disturbances may, 
within a short time, exhibit themselves in a softened or changed 
condition of the tooth structure, is perhaps responsible for a part 
of the general belief that the teeth decay to a much greater extent 
than usual during pregnancy. 

It should be remembered that nutritive changes in the dentin 
are exceedingly slow, while it is not unreservedly admitted that they 
take place at all in enamel. Hence, while functional disturbances 
in the teeth are quick to manifest themselves in allied tissues, the 
reverse is not the case. A continued fever may cause a great waste 
in many tissues, but it cannot in the teeth, because there are in 
them no absorbents, no lymph system. There is no active circula- 
tion in either dentin or enamel, through which progressive or retro- 
gressive changes may be readily and quickly wrought. The sup- 
posed divergence of the nutrient currents from the teeth to the 
growing child must, then, be largely imaginary, and there can be 
no sudden breaking down of these organs during pregnancy. 

And yet the general impression that the teeth decay more at 
that time than any other doubtless has some basis upon which to 
rest. One explanation may be found in the fact that at such times 
the pregnant woman has something else to take up her whole atten- 
tion, and often intermits the care that she is accustomed to give 
her teeth. Food is suffered to remain upon and between them, 
and fermentation does its perfect work. The pregnant woman 
sometimes has perverted or unnatural appetites, and takes into her 
mouth deleterious substances. Mineral tonics are frequently pre- 
scribed for her, and these may bring about destructive results. 
But there is little doubt that the fact that at least a year passes in 
which she is without the dentist's help is the principal factor in 
the result attained. Poor people, who never care for their teeth, 
find little difference between the period of gestation and any other. 

The fear that a visit to the dentist must result disas- 
trously is a mistaken apprehension. It is the true office of the 
oral practitioner to relieve pain, and not to cause it. Every woman 
who finds herself pregnant should visit her dentist, if he is a com- 
petent man, should tell him her condition, and place herself in his 



DISEASES OF THE MAXILLARY SINUS. I25 

hands for such measures as are necessary. He will take special 
care to avoid giving her pain at such a time, not because it would 
always be immediately hazardous, but from the necessity for pre- 
serving her mental and nervous equilibrium to as great an extent 
as is possible. If there are cavities of decay that would be 
likely to bring about complications before the time for her delivery, 
they should be filled, usually with plastic materials. If there are 
troublesome teeth, so badly diseased as to forbid conservative 
measures, they should be promptly extracted. If the administra- 
tion of a general anesthetic is essential, she should be referred to 
her medical attendant. If from the performance of any such neces- 
sary operation, when carefully and skillfully done, any ultimate 
harm has ever occurred, it has not been made a matter of record, 
and the world is in ignorance of it. It should not be forgotten 
that the pregnant female is usually in a state of exalted nervous 
sensibility, but that does not necessarily imply that all operations 
upon the teeth are inhibited. 

That there is more toothache during gestation than at other 
times may be quite true, but there are often sympathetic disturb- 
ances, without real tooth lesions, that have their origin in the 
disordered nervous condition. Concerning the nutrition of the 
teeth of both mother and child, and the prevailing belief that these 
can be governed by any specially regulated diet, another chapter 
will have something to say. 



CHAPTER XXXIV. 

DISEASES OF THE MAXILLARY SINUS. 

The antrum of Highmore, or the maxillary sinus, is a cavity 
within the superior maxilla, connected by a small opening with the 
air passages of the throat. It allows proper contour of the face 
without the weight of bone that would be the consequence of 
solidity. It also makes the nutriment of the bone more easy, and 
obviates any necessity for a large medullary portion. J3ut its 
principal utility is in giving resonance to the voice. All musical 
instruments have a hollow chamber of some kind, to increase the 
reverberations and reflect the vibrations of the air. The perfection 
of the instrument and its quality and volume of tone depend very 



120 ORAL PATHOLOGY AND PRACTICE. 

largely upon the particular form of this reverberator}- chamber. 
Many years of experiment have not been able to devise any benefi- 
cial modification of the peculiar shape of the body of the violin, as 
it was fashioned by Guarnerius. Any departure from that model, 
whether accidental or intentional, has been found to change the 
character of the vibrations and impair the tone of the instrument. 

The antrum is the principal sounding-chamber of the human 
voice, and the wide variations in the character of the tones produced 
are due in a large degree to the size, shape, and condition of the 
cavity. The howling monkey, whose voice can be heard at the 
distance of several miles, has an additional chamber to reinforce 
the reverberations of the antrum. All are aware of the peculiar, 
hard, metallic, unmusical tone that is communicated to the voice in 
cases of empyema of the antrum, or in atresia of the communicating 
sinus. 

The size and shape of the antrum in different individuals varies 
as greatly as do the characteristics of the voice. In some it is large, 
and occupies the whole center of the bone. The two antra in the 
maxillae have even been known to be a continuous cavity, united 
by a communicating opening across the symphysis. Usually, how- 
ever, its anterior limit is the canine fossa. It is sometimes par- 
tially divided into a number of chambers by septa passing across 
its floors. 

The opening by which it communicates with the air passages is 
at the point of junction of the ethmoid and palate bones and the 
turbinated process of the superior maxilla. This is usually at or 
very near its highest point. Dr. M. H. Oyer, of Philadelphia, has, 
by his dissections and studies of the cranial bones, added largely 
to our knowledge of the structure and configuration of this cavity ; 
and Dr. Thomas Fillebrown, of Boston, has given us yet further 
illumination. 

The commencement of the formation of this cavity is not until 
early childhood has been passed. Hence antral disorders are un- 
known in infancy, because there is then no maxillary sinus to 
become diseased. 

The mucous membrane lining the antrum is continuous with 
the Schneiderian, or that covering the bones and cartilage of the 
nasal cavity. It will therefore be liable to the same diseases and 
be materially affected by the condition of the air passages. In- 
flammations and degenerations of the Schneideria:: membrane, by 



DISEASES OF THE MAXILLARY SINUS. 12"J 

mere continuity may be communicated to the antrum, and a nasal 
catarrh may induce a chronic antral disorder. This will be the 
most fruitful source of the degenerated conditions so often present, 
and if what has frequently been asserted is true, that in the northern 
and eastern parts of the United States the person who is entirely 
free from catarrhal troubles is an exception, it must necessarily 
follow that most of the residents of those sections have disor- 
dered or inflamed antra, and this may account for the nasal tone 
said to be characteristic of their voices. 

The roots of decayed and devitalized teeth may sometimes 
penetrate the floor of this cavity and become points of irritation and 
of infection. It does not seem probable that any healthy root can 
actually pierce the floor. The very conditions of the formation of 
the apex demand its investment by the pericementum, and that 
being a double membrane its functional activity implies a septum 
of bone upon its ultimate surface. Accordingly, in the examina- 
tion of antra it is found that the apex of the root of a premolar or 
molar tooth that might otherwise be within the cavity is covered 
with a thin septum of bone that forms a distinct eminence upon the 
floor, and no tooth that reaches the level of the antral floor is with- 
out this. When, however, there is a devitalization of the pulp, 
with a consequent pericemental inflammation at the apex, the 
nature of that affection implies an absorption of the bone that forms 
the septum; and then the end of the tooth might be within the 
antral walls, perhaps perforating the mucous membrane. Under 
such circumstances the apical pericementum would be lost, and the 
root to that extent denuded. 

If an abscess formed it might discharge into the sinus, but such 
a condition would not be likely to exist, because there must be 
investing tissues capable of affording a continuous supply of plastic 
lymph to form the basis of the pus discharge. As this would not 
be the case when the apex of the root actually lay within the 
antrum, penetrating the lining, a chronic abscess discharging into 
the antrum is not probable. The projecting root, however, could 
undoubtedly prove a continuous source of irritation to the lining 
membrane, and thus be the cause'of a persistent inflammation, 
which in due process of time would induce a condition of degenera- 
tion of the mucous follicles, with ultimate breaking down of their 
structure. In this manner the roots of dead teeth may be un- 
doubtedly the cause of actual empyema. 



125 ORAL PATHOLOGY AXD PRACTICE. 

Traumatism is, probably, more frequently than many 
persons are aware of, the origin of actual degenerations. 
Teeth are too often extracted with a degree of violence that would 
never be condoned in the general surgeon. The fact that the 
alveolar walls are exceedingly vascular, and that injuries are healed 
more readily than in any other osseous tissue, alone saves the 
patients of many harsh dentists from most serious consequences. 
There are more fractures of alveolar walls, even to the depth of the 
maxillary sinus, than most people would imagine. There are few 
practitioners who have not seen cases, either in their own practice 
or that of others, in which a part or the whole of the septa of the 
molar teeth was removed, making a considerable opening into the 
antrum. 

The presence of foreign substances sometimes induces 
a diseased condition. Into a cavity, accidentally made, may 
penetrate some extraneous matter that will remain a source of irri- 
tation, or the root of a tooth may be forced into the cavity in 
extraction; and as long as this remains the degeneration will be 
kept up. 

It has been demonstrated that the infundibulum, through 
which the frontal sinus discharges its secretions, in a considerable 
number of instances at least, opens into the apex of the antrum 
instead of into the meatus of the nose. Normally, the opening is 
separated from the mouth of the infundibulum by such a thin 
septum that it is readily broken down by any diseased condition. 
In such instances any vicious secretions from the frontal sinus 
would form the initial point for degenerations in the antrum. 

Whatever their source of origin, the usual phenomena pre- 
sented by antral diseases are those of disordered mucous membrane. 
The probable steps in the degenerative process are, first, a 
hyperemia, to be succeeded by congestion and suppression of the 
mucous secretion. Then follows an active state of inflammation, 
with degeneration of the mucoid follicles, and perhaps a profuse 
watery discharge. This may continue for a time, when, if the irri- 
tation is continued, further degeneration takes place, with final 
breaking down or ulceration of the surfaces. The mucous mem- 
brane thus destroyed, and the periosteum devitalized, there is no 
longer normal nutrition for the bone, and a progressive caries of 
this tissue, or even necrosis, with a profuse discharge of pus, will be 
the consequence. 



diseases of the maxillary sinus. 120, 

Symptomatology. 

The symptoms attending 1 the early stages of catarrh of the 
antrum are not very marked or distinctive. There will be a feeling 
of dryness, with its characteristic pain in the antral region, and 
possible pressure. The latter symptom, however, more distinc- 
tively belongs to a later period. The general phenomena are those 
of catarrh of the air passages. 

These are perhaps succeeded by profuse watery secretions, 
which may quite fill the antral cavity and produce that feeling of 
pressure and the changes of voice that are so often observed in 
acute coryza. This will pass away with the other prodromata of 
empyema. 

Finally, with repeated attacks of the acute inflammatory pro- 
cess, there begins a degeneration in the follicles themselves; the 
disease assumes a chronic form, which results in the complete 
breaking down of the tissue and an empyemic condition. Pus may 
be formed in such quantities that the antrum is filled, with complete 
atresia of the natural opening, and a distressing distention is the 
result. 

The feeling of pressure under such conditions will be severe. 
There will be the usual septic fever, and the superincumbent tis- 
sues will be hot and irritable. If this breaking down of the tissue 
and the formation of pus continues, there will be dilatation and pro- 
trusion of the antral walls at their weakest point. This may be in 
tin- orbital region, and the eye may be actually forced partly out of 
its socket. It may be at the basal walls, in which case the pro- 
trusion will be above the roots of the teeth; or it may be at the 
palatal processes of the maxillary, and the protuberance be into the 
oral cavity. 

The general symptoms will be nearly the same if the 
origin of the disorder is other than that of nasal catarrh. 
If tin' Frontal sinus is diseased, and its depraved contents arc dis- 
charged inn. die antrum through a misdirected infundibulum, the 
prodromata will be more brief in their course, hut the pathological 
changes will not materially differ. The same may be said of the 
presence of foreign substances in the sinus. The character of the 
changes will be those that are usual in inflammations of mucoid 
surl.'i 



I30 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XXXV. 

TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 

The prognosis is usually good, provided all sources of irritation 
can be removed; and, as in all inflammatory processes, the first 
attention should be paid to this point. If the trouble is taken in its 
early stages of simple catarrhal inflammation, the usual remedies 
for that affection should be employed. Nasal douches of 
erethymol, listerine, or borolyptol, diluted with from three to five 
volumes of water, may be frequently used for irrigating the nasal 
mucous membrane. If these cause pain, a little cocain may be 
added. For the ordinary colds, that seem likely to run a chronic 
course, with first a dry, heated condition of the mucous membrane, 
followed by a muco-purulent discharge, the following may be used, 
as recommended by Dr. E. C. Kirk: 

3J — Borolyptol, oj ; 

Cocainae hydrochlor., gr. ij ; 

Aquae dest., oiij. 
Sig. — Use as an irrigating douche. 

In the acute stage of coryza the following will be found useful : 
IJ — Acid, carbolici, oj^; 

Alcoholis, 3ij; 

Aq. ammoniae fort., oj ; 

Listerine, oiij. 

Sig. — Pour half a teaspoonful into a cone made of blotting-paper and 
inhale. 

In addition, for the relief of the antral congestion, a saline 
cathartic may be given, its operation to be followed at bed-time by 
one-sixth to a quarter of a grain of sulphate of morphin, dissolved 
in an ounce of acetate of ammonia liquor. 

With relief for the catarrhal inflammation the antral complica- 
tion will pass away. But if there is any filling up of the sinus, 
either hydromatous or empyemic, it must be opened. This is 
accomplished by penetrating the walls with a trocar. To obtain 
perfect drainage it is absolutely essential that this be done at the 
correct point, otherwise some of the cavity will continue to be 
bathed in the vitiated fluid. Usually the lowest depression is found 
just anterior to the first molar tooth, but this is by no means 
universally the case. Sometimes the antral cavity does not reach 
anterior to this, and occasionally it lies considerably farther for- 



TREATMENT OF DISEASES OF THE MAXILLARY SINUS. 131 

ward. If the thumb and finger are made to grasp the alveolar and 
palatal processes, and the oral region thus carefully examined, one 
may be able to determine the point at which the divergence of the 
walls marks the beginning of the cavity. 

If the first permanent molar has been removed, the best place 
for making an opening will be at that point. If it be much decayed 
it will be wise to extract it and drill or puncture through the socket 
of its lingual root. Care must be taken to avoid following too far 
in the direction of the root if it diverge much from the others. The 
drill, or trocar, should be pointed in the proper line. The best 
instrument is a twist drill in the dental engine. The cavity once 
reached, the aperture should be expanded with a reamer until it is 
at least as large as a common lead pencil. An opening less than 
this will be likely to become closed. It is not usually a formidable 
operation, or one attended with a great deal of pain, but in most 
instances it will be advisable to administer an anesthetic. 

The opening once made, a little time should be given for its 
drainage, when it may be washed out with tepid water in which 
a little salt has been dissolved, thrown into the cavity with a 
syringe. This may be repeated until the cavity is quite clean, when 
a disinfectant, like peroxid of hydrogen or electrozone, warmed 
to blood temperature, may be substituted. Care should be taken 
to dilute it if peroxid of hydrogen is used, for if much pus remains, 
and it be injected pure or nearly so, violent and painful foaming 
may be the result. 

If the opening is of sufficient caliber and made at the lowest 
point very little treatment will, in cases uncomplicated with dis- 
charges from the frontal sinus or foreign growths or substances, be 
demanded. A disinfectant simply decomposes septic matter, and 
there is necessarily nothing therapeutic in its nature aside from 
this. It is better to wash out the pus than to decompose it, for its 
elimination will be more perfect and more readily brought about, 
provided the opening is completely patulous. 

The cavity having been cleansed, the next step will be 
to secure continual drainage. For this purpose the insertion 
of a drainage tube has been recommended, but this, it is believed, 
will seldom be found necessary; and there are conclusive reasons 
for its rejection, if that be possible. 

The drainage tube that has usually been employed is of metal. 
It is very difficult to retain in position one of any" other kind, be- 



132 ORAL PATHOLOGY AND PRACTICE. 

cause adhesive plaster bandages, and the methods by which such 
are usually held, are inadmissible in the mouth. A metal drainage 
tube must of necessity act as a continual irritant and become a 
focus of inflammation and of infection. It is almost impossible 
accurately to adjust its length, and if it should once be perfectly 
adapted it will not remain so. If the upper end projects above the 
floor of the antrum it will not afford perfect drainage, and if it does 
not it will fill and become stopped with granulations more readily 
than an opening without such a tube, because its irritant presence 
will stimulate hyperplastic growths. 

It will seldom be the case that a drainage tube will be 
needed if the opening is sufficient. Should the mouth of it 
not remain patulous, the granulations should be cauterized or cut 
away. This will be better for the disorder than to allow them to 
grow about a drainage tube. If the orifice is kept dehiscent, open 
and gaping, the drainage will remain perfect, and the diseased con- 
dition will not be perpetuated by retention and further degenera- 
tion of the septic product, even for an hour. 

Tents and plugs for the perforation should be avoided. 
They are an irritation, retaining within the antrum the septic 
products that should be removed or allowed to escape as soon 
as formed. Even a moment's restraint is evil in its tendency. 
The sole excuse for their employment is that they prevent the 
entrance of food, saliva, etc., from the mouth. There is no cause 
for anxiety from this source, for saliva will not enter against 
the force of gravitation, while food and debris can only penetrate 
when forced in, and these are usually spontaneously eliminated 
before fermentation can take place. But even if there is a liability 
to the intrusion of foreign matter through an unstopped orifice, the 
possible resulting injury could not be as great as that arising from 
an impeded drainage. If the natural foramen of the antrum is 
closed the artificial opening must be kept unstopped, because com- 
munication with the outside air is a necessity. As well might one 
seal up the drum-hole as entirely to close the antrum, which, as has 
already been said, is a reverberatory chamber. 

The employment of tents and plugs has resulted in 
very serious injury at times. It will doubtless have been found 
by most oral surgeons who have had a considerable experience 
in the treatment of antral disorders, that the most obstinate and 
incurable cases were those in which a comparatively small aperture 



TREATMENT OF DISEASES OF THE MAXILLARY SINUS. I33 

had been made, with the subsequent attempt to keep it open by- 
tents, distenders, and drainage tubes. It has become the common 
usage of those who have acquired skill by extensive practice in 
these cases, first of all, carefully to explore the antrum for lost plugs 
and dressings, or parts of such, which are certain to perpetuate the 
disease. Any oral surgeon can call to mind more than one in- 
stance of this. The author has never met with a case of persist- 
ent antral degeneration, in which it was possible to remove the 
source of irritation, which was not healed with comparative readi- 
ness if drainage was left free and unimpeded. He has frequently 
met instances in which no relief was obtained until a dressing or 
other foreign substance that had lodged in some depression in the 
floor had bee found and removed. In one case it was a piece of 
iodoform gauze more than six inches in length. 

Perfect drainage having been secured, there are com- 
paratively few cases that will demand anything more. 
The use of the drastic and irritating remedies and solutions that are 
so frequently injected is to be avoided. Cleanliness once assured, 
the vis medicatrix natures will usually do the rest. A considerable 
number of instances from daily practice might here be cited, in 
which a profuse, long-continued, and exhausting empyemic dis- 
charge was entirely cured by a proper operation, the permanent 
removal of all plugs and tents and dressings, and a thorough wash- 
ing out and disinfection of the sinus. 

The irregularities in the shape of some antra insure the in- 
definite continuance of the septic state unless some further surgical 
interference than the mere perforation of the floor is provided. 
Occasionally septa will be found crossing the cavity, and dividing 
it into partially separate chambers. Depressions in the base will 
be encountered, which will retain septic matter. If the opening 
lias been made sufficiently large, a bent silver probe may be used 
to explore for an)' lamina and dividing walls, and for intrusive 
foreign substances. When their nature will permit, any septa 
should be broken down, and when this is nut practicable the patient 
should be directed occasionally to incline the head in such a man- 
ner that any retained fluids may flow <>ut toward the drainage open- 
ing, ('are should also he used frequently to wash oul such depres- 
sions and partial chambers, and to keep them thoroughly disin- 
fected. 

The author has in some instances found it impracticable to 



134 ORAL PATHOLOGY AND PRACTICE. 

make an opening sufficient for all this work through the floor of the 
antrum, and has broken down the alveolar walls until the end of the 
finger could be introduced for exploratory purposes. Such an 
aperture gives entire access to every part of the sinus, and enables 
the operator to determine the presence of necrosed conditions, and 
to extirpate dead tissue, if it be not of too great proportions. 

There will be instances in which, from a general atonic or 
anemic state, some cachectic condition, or special degeneration like 
necrosis, there is not a speedy return to health. The inflammation 
may assume a low, subacute, or chronic stage, and the indolent 
tissues refuse to respond to the treatment indicated. In such cases 
more rigorous measures must be inaugurated. After disinfection 
a solution of three to five grains of chlorid of zinc to the ounce of 
water may be injected, and made to reach every part. This will 
act as an antiseptic and a stimulating astringent, and probably 
bring about an altered condition. If it be insufficient, it may be 
used in still stronger proportions, the production of painful and 
irritating symptoms being the guide for its limitation. 

If there is pain, it may be treated by an injection of dilute 
wine of opium. In case of a profuse discharge from an ulcerated 
mucous membrane, a solution of zinc sulphate, one dram to the 
ounce of water, may be used. When there is a great deal of fetor 
a solution of potassium permanganate, ten grains to the ounce of 
water, will be found useful. Carbolized solutions may be 
employed, the avowed aim being to produce a temporary aggrava- 
tion of the inflammatory symptoms, or to change the chronic con- 
dition to one that is more acute. 

If the degenerative process shall have proceeded so far as to 
involve the bony walls, an operation for the removal of the dead 
tissue will be necessary. Whenever the symptoms lead to the con- 
clusion that depraved secretions from the frontal sinus are dis- 
charged into the antrum, the opening should be kept patulous and 
the attention directed toward the other cavity that is the source of 
the disease. 

An opening through the bone of considerable size, that has 
served for the drainage of pus, will not always entirely close. This 
will not materially matter, because there will usually be a formation 
of soft tissue and mucous membrane over it that will be sufficient 
for the exclusion of foreign matter. Even if this is not accom- 
plished little inconvenience is experienced, provided nothing is 



DISEASES OF THE FRONTAL SINUS. I35 

kept in it that can retain food until it ferments within the sinus. 
It will not be in a worse condition than are the nasal passages in 
cases of cleft palate. It may be necessary periodically to wash out 
the antrum, but this can readily and easily be accomplished; 



CHAPTER XXXVI. 
DISEASES OF THE FRONTAL SINUS. 

This is another of the cavities connected with the air passages, 
and the reasons for its existence are the same, though of less 
importance than in the case of the antrum. As the cavity is much 
smaller, and as sometimes it is entirely absent, its pathological 
complications are less in number and of smaller import. As in the 
case of all other open cavities it is lined with mucous membrane, 
and its diseases will be the same as those of the maxillary sinus, 
except as they are modified by the different environments. It is 
probable that they seldom originate in the sinus itself. 

Inflammations and degenerations of the lining membrane will 
comprise the most of these, and, while the presence of foreign sub- 
stances may be eliminated from the list of causes inducing them, 
the pathological changes will be so nearly analogous that a 
recapitulation of these is unnecessary. In edemas and empyemas 
the discharge is through the infundibulum that penetrates, the 
ethmoid, and into the middle meatus of the nose. The diagnosis 
of these conditions must be through the tracing of this vitiated 
matter to its source, and from the sense of fullness and pressure 
that will inevitably be felt in the supra-orbital region. 

Local treatment will be impossible unless an opening is made, 
which will be from the lower border of the bone, through the 
supra-orbital prominence or ridge into the cavity, where it may be 
treated as in the case of the antrum. But this is a very unusual 
operation, and seldom called for except in cases of atresia of the 
discharging duct or canal, or when the discharge has induced a 
degenerated condition of the infundibulum, or is flowing into the 
maxillary sinus. 

Thai these latter conditions may exist and may induce serious 
complications, the following case in the practice of Prof. Truman 
\V. Brophy amply demonstrates. Miss A. had for some years 



136 ORAL PATHOLOGY AXD PRACTICE. 

suffered from what was pronounced antral disease. Five opera- 
tions for its relief had been made by different surgeons, most of 
them consisting of the usual opening and flushing of the sinus with 
antiseptic and stimulating solutions. It was now determined to 
explore the cavity more completely than had yet been done, and to 
this end the maxillary walls above the roots of the teeth were 
removed until the finger could be introduced. No foreign sub- 
stance or growth was found, and the cavity was temporarily packed 
with antiseptic gauze. At a subsequent visit this was removed and 
the antrum critically examined. Xear the apex purulent matter 
from some superior source was observed to percolate into the sinus. 
The connection of the frontal sinus with the diseased condition 
had not previously been suspected, but in the light of the then 
newly published observations of Dr. Cryer it was at once apparent. 
Thje infundibulum was discharging pus into the antrum, and the 
seat of the disease was either in the frontal sinus or in the ethmoid,, 
and a further operation was at once determined upon. At the 
proper time the supra-orbital tissues were divided, the filaments 
of the supra-orbital nerve dissected out and an opening made into 
the frontal sinus, from which pus at once welled up. The opening 
was now extended the whole length of the sinus, until a probe 
could be thrust down through the infundibulum for a considerable 
distance, when its point was found in the maxillary sinus. Careful 
probing now demonstrated that the cells of the ethmoid were in a 
degenerated condition, and that the connecting passage was for a 
part of its length devoid of its membranous lining. With the 
properly shaped burs in the surgical engine the incision was carried 
along the course of the infundibulum until the center of the nasal 
bone was reached. A considerable opening was made in this bone, 
the degenerated portions of the ethmoid were removed, the surfaces 
of the discharging canal freshened and its mouth made to open into 
the nasal meatus instead of into the antrum. A drainage tube was 
now inserted into the frontal sinus, through which the whole terri- 
tory could be flushed, and the wound was closed about it. The dis- 
charge was for some time very profuse, but continued antiseptic 
treatment finally resulted in a complete cure. When the infundib- 
ulum was made to discharge into the nasal cavity the trouble in 
the antrum was at once relieved, and never returned, thus conclu- 
sively proving that the source of disease was not in this sinus, 
which was onlv secondarily affected from the frontal sinus. 



CYSTS AND THEIR TREATMENT. 1 37 

CHAPTER XXXVII. 

CYSTS AND THEIR TREATMENT. 

A Cyst is a tumor containing a cavity or cavities filled with, 
fluid or semi-fluid contents. In one sense, it is nature's method of 
isolating from the tissues any foreign or irritating matter. It is 
the only way in which extraneous substances can be permitted 
permanently to remain in the animal economy. 

When cysts consist of a single chamber they are simple, and when 
divided by membranous septa nudtilocular. Should they contain teeth 
they are called dentigcrous cysts. 

A cyst may also be the result of the stoppage of some 
duct, and the consequent retention of the secretion of the 
gland of which it was the discharging canal ; or it maybe 
the mere collecting of a watery fluid in a previously existing 
serous cavity, the outcome of functional disturbance. 

A cyst consists of a membranous pouch, without an opening, that 
envelopes the alien substance when such exists, and separates it from 
the tissues. In like manner a colony of bees, when some animal or 
offensive substance which they are unable to expel gains entrance 
to the hive, seal it up and segregate it by covering it with an im- 
penetrable coating of wax, within which it loses its repulsiveness. 
A cyst is filled with a fluid in which the offending matter floats or 
is contained, thus preventing its immediate contact even with the 
cyst walls. 

Cysts are developed in a natural cavity of the body, or within 
the substance of an organ. They cause a distention that with the 
continual gathering of the cystic fluid and the constant growth of 
the cyst sometimes becomes of enormous proportions. It is only 
through their expansion that they assume any dangerous character, 
for they do not otherwise cause functional disturbances. They 
may readily he distinguished, in most instances, through this 
peculiarity, and through their slow formation and the entire lack 
of pain that accompanies their growth. 

The methods of distinguishing them from tumors are various. 
If they are accessible, the fluctuation of the fluid contents may 
readily he perceived. Sometimes, when they have existed for a 
Ion- period without materially growing,a parchment-like crackling 

will he felt upon pressure, and it ma\ even he heard with the ear. 



I38 ORAL PATHOLOGY AND PRACTICE. 

It sounds very much like the crepitating sound produced by the 
flexing or bending of bar tin. This is because of the inspissation, 
or thickening into a grumous, clotted mass of the fluid contents, 
through their desiccation, or drying. In deeper cysts it is usually 
advisable positively to determine their character by aspiration, or 
the drawing off of some of the fluid contents, by means of an 
aspirating or hypodermic syringe, and its careful examination. 
This gives a positive method of diagnosis. An exploring needle 
should also be used, to determine the presence of any foreign or 
irritating substance. 

Park, whose "Surgery by American Authors" may be ac- 
cepted as the most modern expression of surgical pathological 
knowledge, divides these ordinarily benign tumors into four 
classes: 

1. Retention Cysts. These imply a previously existing cavity, 
whose outlet is stopped up, and whose contents consequently accumulate 
and perhaps degenerate. This class will of course include those oral 
cysts which arise from an obstruction of the ducts of the salivary 
gland. 

2. Tubulo-Cysts. These arc dilatations of certain functionless 
ducts in other parts of the body. They are largely developmental in 
their origin. 

3. Hydrocele. This, as its name indicates, is a collection of 
watery fluid in sonic serous cavity, one which has no discharging duct 
and no opening of any kind. Hydroceles are apt to be of congenital 
origin, and are most frequently found in the region of the neck. 

4. Glandular Cysts. These gracilis arc formed by the dilata- 
tion of certain glands. They may usually be classed as retention 
cysts, for the enlargement is most commonly induced by a stop- 
page of the ducts. They may, however, occur in connection with 
the ductless glands, and because of this there is a degree of pro- 
priety in distinguishing them from those which arise from the mere 
closing of a duct. 

Those which are of interest to the oral surgeon or physician 
are the first and last classes, tubulo-cysts and hydroceles not 
being likely to fall under his observation. 

Cysts in and about the oral cavity are quite frequent, a con- 
siderable proportion of them being caused by calcareous deposits 
within the salivary glands or in their discharging ducts, and the 
subsequent formation of a retention cyst. 



CYSTS AND THEIR TREATMENT. 1 39 

Ranula is a retention cyst, caused by the stoppage of Wharton's 
duct, or one of the mucous glands beneath the tongue. A small cal- 
culus may be formed within the gland, and it will eventually- 
become lodged somewhere in the duct, completely stopping it. The 
saliva or mucus is obstructed and forms a cystic pouch or pocket, 
into which more is continually flowing. The watery portion will 
be lost, and there will remain a thick, jelly-like mass beneath the 
tongue upon one side, which in some instances thrusts that organ 
quite out of the mouth. It assumes a peculiar mottled appearance, 
closely approaching that of a frog's belly, and hence it has received 
the name of ranula, from the. Latin rana, a frog. 

Odontocele or Odontoma is another comparatively common form of 
oral cncystmcnt. These are caused by the presence of an undeveloped 
or misplaced tooth-germ. The former term more strictly applies to 
a cystic, and the latter to a degenerate formation, although both are 
due to the same cause and are of the fame general character, 
They may appear at any point of the jaws, wherever the undevel- 
oped germ may exist. They are easily diagnosed in most in- 
stances, not only by the means already laid down, but by the addi- 
tional fact of there being a missing tooth, and by their location 
where that might naturally be expected to exist. 

There are other forms of cysts arising from some functional 
disturbance in the smaller glands of the mouth and tongue. They 
belong to the strictly glandular class, and consist of an enlargement 
or dilatation of a mucous gland. Such an one is frequently found 
just at the tip of the tongue, where lies the so-called Nuhn's gland. 
These cysts, however, may be of the simple retention variety, due to 
a stoppage or closing of the duct of the mucous follicle. Dermoid 
or congenital cysts are also sometimes found in the mouth. 

Sometimes the cystic formation is within the antrum 
of Highmore, which it fills with cystic fluid. In this locality 
it is liable to be mistaken for an ordinary edema <>f that cavity. 
But after it lias existed for some time it usually causes an absorp- 
tion of the walls Hi' the antrum, when its true nature is revealed. 
This will most often occur at the external extremity of the antral 
cavity, where the alveolar walls arc thinnest. At thai point, 
beneath the cheek, fluctuation may readily be observed, and the 
peculiar feeding of the cystic fluid may easily be detected. If there 
is yet any <1< ml it, an aspirati »r needle ma) be introduced, and a little 



I40 ORAL PATHOLOGY AND PRACTICE. 

of the fluid extracted. If this is thick and glairy, with perhaps 
some flocculent matter floating in it, the diagnosis will be clear. 

There is a kind of cyst that is of a distinct interest to the dentist, 
viz, the ovarian dermoid. These dermoids are teratomatous growths, 
made up of matter that is developed from the epiblastic layer. Hence 
we find them containing epithelia. skin, hair, sebaceous glands, and 
well-developed teeth. If they should contain bone, muscle, or 
nerve tissue they would not be dermoids, because these are of 
mesoblastic origin. The author has in his possession a dermoid 
ovarian cyst that contains nearly forty teeth, some of them decidu- 
ous and some permanent, with hair rolled up into a ball and nearly 
two feet long. 

The treatment of cysts is usually quite simple. In most cases 
it is sufficient to first open the cystic tumor, and explore it for the 
presence of an irritating agent. This, when discovered, may be 
removed. The contents of the cyst should now be thoroughly 
evacuated, and the cavity washed out with a weak disinfecting 
solution, when the whole may be packed with iodized lint. Granu- 
lations will usually commence and complete the cure. It may be 
desirable to wash out the cayity with a stimulating fluid, and wait 
a little time to see that no undue inflammation succeeds, before the 
iodized lint is used. 

In cysts within the bone, or in the antrum, septa may 
exist, partially dividing the cavity into two or more por- 
tions. These should usually be broken down, that the diagnosis 
may be complete. This will be found especially true in the maxil- 
lary sinus. 

In ranula, it is desirable to remove the obstructing cal- 
culus and evacuate the cyst without cutting, if it be possi- 
ble, that the course of the duct may not be changed. A little 
careful manipulation will not infrequently be effectual in driving 
the concretion, if it is not too large, out through the course of the 
duct, when the contents of the cyst may be removed by means of 
the aspirator. Should the cyst again fill up, it may be necessary to 
open it, but the natural discharge from the submaxillary gland 
should be carefully provided for. There are instances in which it 
will be found necessary to dissect out as much of the connecting 
membrane as is possible. There is little danger from bleeding in 
any operation upon cysts, if carefully performed, and the only com- 
plications are those arising from the ordinary inflammations. 



TUMORS AND NEOPLASMS. I4I 

CHAPTER XXXVIII. 
TUMORS AND NEOPLASMS. 

It is not the purpose of this work to enter upon any extended 
investigation of diseases not commonly encountered by the dentist, 
or which properly belong to the practice of the general physician, 
or that of any other specialist. But it would not be complete were 
not a sufficient knowledge of morbid growths imparted to enable 
the student intelligently to diagnose the condition, even were it 
essential for him to refer his patient to the general surgeon for any 
necessary operation. Hence, some general remarks will be at- 
tempted concerning the origin and pathology of the more common 
foreign growths. 

The term Tumor implies an abnormal enlargement of any part 
from any non-inflammatory cause, hut usually from a morbid 
growth, which in its structure conforms to a greater or less extent 
to the tissue in which it grows, and which has no functional action. 
A simple inflammation is a tumor in one sense, but not in that 
which is surgically the accepted one. The term Neoplasm is more 
applicable to the conditions under consideration, because it implies 
an abnormal growth, which may be either normally or abnor- 
mally located. 

All neoplasms, or tumors, consist of tissue that belongs to the 
body, and that forms an essential part of it when properly devel- 
oped. But when any tissue of the body grows in a location that is 
foreign to it, or when it develops in an abnormal manner, or in 
excessive amount, it becomes a tumor or neoplasm. Every hyper- 
trophy is a tumor, because it is an excessive development, though 
of a normal tissue in a natural locality. If it is developed in an un- 
natural position, there is a greater departure. If fibrous tissue 
develops unconnected with other such tissue, or in a place in which 
fibrous tissue does not belong, it is a neoplasm. It osseous tissue 
develops in undue amount in connection with other hone, it ma_\ be 
but an hypertrophy or a hyperplasia. Bui if it is formed in an ab- 
normal manner, or in an unnatural location, it becomes a morbid 
tumor. A wart is the undue development or an hypertrophy of one 
or more of the papillae of the skin, and it is thus a form of benign 
tumor. A corn is the impaction of the epithelia in the tissue be- 
neath, hut it is not a true foreign growth. When epithelia develop 



142 ORAL PATHOLOGY AND PRACTICE. 

unduly in the midst of other tissues, they form a dangerous kind of 
tumor. 

Neoplasms may be of benign or of malignant growth. In the 
former case the tissue elements may form a mere harmless hyper- 
trophy, like hypercementosis, sometimes called exostosis of a tooth, 
while in the latter they are essentially foreign, and therefore irri- 
tants, and cause a degeneration and breaking down of tissue. All 
neoplasms, therefore, are composed of normal cells, abnormally de- 
veloped in number, as in hypertrophies; in position, as in warts, 
moles, etc. ; or in both location and histological arrangement, as in 
the malignant tumors. 

They are named according to the tissue in which they 
occur, or of which they are composed. 

An Epithelioma is composed of unduly developed cpithclia. 

A Fibroma is composed of unduly developed fibrous tissue. 

An Osteoma is composed of unduly developed osseous tissue. 

An Adenoma is composed of unduly developed glandular tissue. 

An Enchondroma is composed of unduly developed cartilage tissue. 

A Myoma is composed of unduly developed muscular tissue. 

A Glioma is composed of unduly developed nerve structure tissue. 
'An Augcioma is composed of unduly developed blood tissues. 

A Myxoma is composed of unduly developed mucous and gelat- 
inous tissue. 

Tumors are also named from other peculiarities, as — 

Sarcoma; having the appearance of flesh. 

Encephaloid ; having the appearance of a head. 

Myeloid; having the appearance of marrow. 

Melanotic; having a pigmented or colored appearance. 

Scirrhus; having a hard appearance or consistency. 

Medullary; having a soft appearance or structure. 

Tumors are also Homologous or Heterologous, the former con- 
sisting of tissue like, and the latter unlike, that in which it is im- 
bedded. Homologous tumors naturally are apt to be benignant, and 
heterologous tumors to be malignant in their nature. 

Malignant tumors are usually connected with some 
peculiar diathesis, and there is an hereditary tendency to- 
ward their formation. They are embryonic in structure; that 
is, not fully developed tissue, and hence quite unlike ordinary 
hypertrophies. They are apt to consist of a network of connect- 



TUMORS AND NEOPLASMS. 143 

ing tissues, whose meshes are filled with abnormally developed 
cells. 

They may be diagnosed from their position, their his- 
tory, growth, pain, general appearance, etc. 

A tumor will usually first appear as a hard nodosity 
within the tissues. It may increase in size very fast, or 
its growth may be slow. It may be accompanied with 
considerable pain, or it may be without functional dis- 
turbance. There are a great many benign tumors to each one of 
a malignant character. As a rule, if the growth is slow and with- 
out pain, if there is no special reason for its appearance, if it can be 
attributed to no particular pathological condition and no functional 
disturbance is connected with it, little attention need be paid to it. 
It is probably one of the frequent hyperplasias of an innocent char- 
acter that may be found in almost every person. It is usually safe 
under all circumstances to allay the fears which such an appear- 
ance almost invariably excites, by the assurance that it is one of the 
numerous growths that can do no harm, and to endeavor to divert 
the mind from all thoughts of it. Nothing should ever be said that 
can excite apprehension. Even if the practitioner is in doubt con- 
cerning its true nature, he should not let the patient become aware 
of it. He should keep it under observation until it has sufficiently 
developed to enable him to judge intelligently, but always without 
communicating alarm. 

The treatment of the homologous tumors is wholly local. They 
have no constitutional origin, and do not menace life. The chief 
reason for interfering at all in many such cases will be found in the 
fact of their causing inconvenience or disfigurement. 

The heterologous tumors represent a constitutional vice. They 
tend to infiltrate into and invade other tissues. Especially are they 
likely to affect the glandular system. Local treatment is entirely 
useless, and even if they are removed they are quite likely to re- 
appear. They never, like the homologous tumors, reach a definite 
limit of growth, but continue to increase and spread. Their treat- 
ment, aside from surgical interference, which is usually advisable 
except in the later stages, must be specific and sustaining. 



144 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XXXIX. 
TUMORS AND NEOPLASMS (Continued). 

The term Cancer is one that is not usually employed by pro- 
fessional men. It is derived from the Latin cancer, a crab, and 
the name is given from the supposed crab-like appearance of the 
veins in this affection. The laity usually understand by it either of 
the malignant growths which are technically called Sarcoma or 
Carcinoma. Of these the sarcomata are composed of embryonic 
tissue from the mesoblastic layer, while the carcinomata are of 
epiblastic origin. Each is variously subdivided according to its 
character or development, and each presents separate physical and 
pathological characteristics. 

Sarcomas have a distinct kind of fleshy appearance, and seem to 
be specially vascular. They grow along the lines of least resistance, 
and are likely to penetrate into cavities and fissures of the tissues. 
They appear at any age, and are comparatively rapid in their 
growth, sometimes causing considerable pain. When they appear 
upon the surface they bleed very easily, and have in such cases 
sometimes been known as Fungous Hematodes. They are com- 
paratively frequent in the salivary glands, in the jaws and other 
tissues of the mouth, sometimes penetrating to the antrum. They 
are quite common in some of the lower animals, especially the 
horse. 

Carcinoma is of epiblastic origin, and is connected with some form 
of gland tissue. It is rare in young persons, and it commonly 
involves the lymphatics at an early period of its development. It 
is usually rapid in its growth, and it may cause a very great degree 
of pain. It is very apt to attack the breast in women, but its seat 
may be in the sebaceous glands, the salivary glands, the prostate, 
liver, kidney, testicles, stomach, intestines, especially the rectum, or 
wherever glandular tissue exists. Hence its location will be an 
important guide in its diagnosis. 

Epithelioma, as its name indicates Js a degeneration of an epithelial 
surface, usually of the skin, and consists of masses of epithelial celh 
surrounded and separated by bands of connective tissue. It belongs 
to the malignant growths, though it does not necessarily assume 
their form. It is most apt to attack those beyond middle life, and 
is much more common in men than in women. It sometimes 



TUMORS AND NEOPLASMS. I45 

arises upon the lip, from the long-continued irritation of a pipe. It 
is also not infrequently caused upon the tongue, or in the oral tis- 
sues, by the pressure of rough, sharp edges in carious teeth, which 
act as a continuous provocation. Its diagnosis is not usually diffi- 
cult. Its late and superficial appearance and the chronic ulcer 
with indurated edges forbid its being readily confounded with any- 
thing else, unless it might be some forms of syphilis. 

Lupus is one of the many forms which tuberculosis 
assumes. It is strictly a communicable disease, and is due to an 
infection by the tubercle bacillus. It usually commences early in 
life upon the face, in the form of small red or dark spots, which are 
much softer than the inclosing tissue. They ulcerate in time, and, 
spreading with the deposition of more tuberculous matter, there is 
a steady erosion into the surrounding territory. The infection of 
the system with the tubercle bacillus is always a grave matter, and 
is liable to cause many complications. It is a question to be taken 
into careful consideration when any surgical measures are contem- 
plated, because the appearance of miliary tubercle would interfere 
with the healing process. It is impossible within the limits of a 
work like this thoroughly to consider the many phases which 
tuberculosis may assume, and the student who desires further in- 
formation is referred to works upon general surgery. 

Of the non-malignant tumors, those most commonly found in the 
mouth are the different forms of fibroma. These, as their name in- 
dicates, are composed of fibrous tissue. They are ordinarily dense 
in structure, and composed of bundles closely packed together, 
which arc permeated by blood vessels. The Epulids belong to 
this class, as they are of fibrous origin. 

Lipomas, or fatty tumors, are the most frequent of any of the 
neoplasms. They are of the adipose tissue type, and it is needless 
to say are harmless in their character. They are usually inclosed 
in a capsule, from which, if no vital organ is involved in these folds, 
they may readily be enucleated. They are easy of recognition, 
ept when deeply located, and when once extirpated are not apt 
to return. 

The Osteomas are bony tumors, and are by some believed to be 
chondromas, or cartilaginous tumors, which hart- ossified. They may 
be cither compact or cancellous in structure. They are mosl com- 
mon about the cranium, and may be found in the Frontal sinus, the 
external auditory meatus, and about the mastoid process. The 

11 



I46 ORAL PATHOLOGY AND PRACTICE. 

compact forms are sometimes very dense and hard, appearing like 
ivory, and they may defy the finest steel instruments. Some forms 
of odontoma are classed with osteomas. 

The student will be especially interested in the methods by 
which tumors of malignant growth may be distinguished from 
those which are benign. This may usually be done by the clinical 
symptoms, although there are instances in which the most careful 
observation will be at fault. Some of the foreign growths will pre- 
sent misleading characteristics, but the following points of differ- 
ence may usually be relied upon : 

Benign tumors are common to all ages, while those 
which are malignant do not appear in early life. 

Benign tumors are slow in formation, while the malig- 
nant are usually of rapid growth. 

Benign tumors do not spread and infiltrate into the 
surrounding tissues, while those which are malignant in- 
filtrate in all cases. 

Benign tumors are often inclosed in a capsule and are 
circumscribed, while malignant tumors are never thus 
limited. 

Benign tumors are rarely adherent, while malignant 
ones always are. 

Benign tumors rarely ulcerate, while the malignant 
ones always do when they come to the surface. 

In benign tumors the overlying tissue is not disturbed, 
while in the malignant it is more or less retracted. 

There is no lymphatic involvement in the benign 
tumors unless they are inflamed, while malignant tumors 
almost always involve the lymphatics. 

The treatment of the tumors is almost exclusively surgical. 
Those which are benign seldom return when they have 
been extirpated. It is not so with the malignant ones. If they 
have made considerable progress, and especially if the lymphatic 
glands have become enlarged and indurated, they are very apt to 
reappear. Yet excision, even of the most destructive forms, will 
usually prolong life, if it does not permanently save it. There is 
but one safe method of removing them, and that is by the knife. 
The eroding plasters of the so-called "cancer doctors" are not only 
the most painful means of effecting removal, but are eminently 
dangerous, being very apt to hasten infiltration, and in some in- 



TUMORS AND NEOPLASMS. \\J 

stances they may convert a tumor of a benign aspect into a malig- 
nant type. 

The dentist will be mainly interested in the epulitic growths 
that are common in the mouth. The term Epulis means "upon the 
gums." Hence it is applicable to any abnormal gingival growth, 
and the hypertrophies that, proceeding from the gums, fill the 
cavities in decayed teeth are true epulids, though of a simple 
character. 

The common form of epulis is a vascular tumor that appears upon 
the gums. Its origin may be from the superficial fibers, from the peri- 
cementum of a tooth, or it may penetrate into and appear to have its root 
in the alveolus. Epulids may appear as erectile or as non-erectile 
tissue, and may have fibrous, myeloid, myxomatous or sarcomatous 
complications. 

The erectile epulids are vascular growths, whose size depends 
upon the vascular condition, and they vary with this. When dis- 
tended they appear tinged and dark. 

The epulitic tumors that spring from the periosteum perhaps 
invade the substance of the bone. They may be diagnosed by 
careful movements, and by the exploring needle, which may pos- 
sibly detect an opening into the bone. 

If the origin is from the pericementum of a tooth, a peduncular 
connection may usually be traced, either through the alveolar walls 
or by the side of the tooth, in the direction of the pericemental 
membrane. 

For the removal of the superficial and erectile tumors, little 
more is needed than a ligature that shall cut off all circulation, with 
final cauterization of the place. An epulis that has its origin in the 
pericementum of a tooth will be cured by extraction. But for 
those which penetrate the bone, it will be necessary to remove as 
much of the alveolus, or even the body of the maxilla, as is affected, 
remembering that the extremity of the invasion must be reached. 
The wound should be dressed with iodized lint. If there is much 
inflammation the following may be applied: 

I£ — Plumbi acetatis, 5ij ; 

Tinct. opii, .">ij: 

Aquae, Sxvj, 

Sig.— Pack the wound with lint wet with the solution. 

I 



I48 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER XL. 
: OSTEITIS. 

Before entering upon the consideration of diseases of the 
bone it is necessary thoroughly to comprehend the pathological 
changes involved in the initial steps of the degeneration. Bone, 
which forms the framework of the body, is made up of an inorganic, 
or mineral portion, and an organic, or living part. The latter is con- 
tained within the meshes of the former, and communicates through 
the whole structure of the bone. This is accomplished by means 
of the peculiar formation of the inorganic part. It is through the 
organic or living portion that nutriment of the whole osseous 
tissue is carried on. The changes that occur in the inorganic 
portion, the waste and repair, are not, of course, as great as those 
of vascular tissue, yet they must be provided for in the economy of 
nature. 

The nourishment of the bone, like that of all other tissues, must 
primarily be derived from the blood, and it is carried on through the 
periosteum or investing membrane, the medullary marrow or central 
cavity in long bones, and the Haversian or penetrating canals which 
carry the blood to all portions of the thick bones. Around the 
Haversian canals, and along all the sources of nutriment, are 
arranged a concentric series of cells containing the essential living 
matter of the bone. These cells are the lacunae; and each of the 
zones of these so concentrically arranged cells is called a lamella. 
Connecting the several lacunae, and communicating with the 
nutrient source — the periosteum, the medulla, or the Haversian 
canals — are the canaliculi, the minute canals which carry the pabu- 
lum extracted from the blood to the lacunae, the immediate source 
of nutriment. 

The living contents of the lacunae and the communicating 
canaliculi are of a protoplasmic or embryonal character, and contain 
the elements of the osseous tissue. If the nutrition of its structure 
is cut off, the bone dies as inevitably as does any other tissue under 
like circumstances. If a ligature is placed about the finger that 
is sufficient to prevent all circulation, and thus to stop all nutriment, 
the soft tissue will die and become gangrenous. If the ligation is 
so complete as to deprive the bone of its nutrient currents, that will 
also die from the same reason, and become necrosed. 



OSTEITIS. 149 

If the stoppage of nutrition in the finger is through a progres- 
sion of the inflammatory process, by hyperemia, congestion, and 
final stasis of the blood current in the part, the result is precisely 
the same as if it were through a ligature, or separation of all arterial 
sources of supply. It matters not by what the nutrition is com- 
pletely interrupted, whether by starvation, stoppage of food supply, 
either to a part or the whole of the body, by cutting off that supply 
through interruption of the channel of conveyance, or by such 
pathological changes as completely to prohibit assimilation of food 
products, death of a part or the whole of whatever is thus deprived 
of its food supply must be the inevitable result. In the soft tissues 
this may be called suppuration, ulceration, sloughing, or gangrene, 
and in the hard portions caries, exfoliation, or necrosis, but it is 
essentially all the same process. Each is but a different manifesta- 
tion of the universal law of death and decay whenever nutrition and 
progress cease. The instant that progression stops, retrogression 
commences. 

The contents of the lucunae and canaliculi of bone, the proto- 
plasmic embryonic elements, although they are not directly vas- 
cular, may be the subjects of inflammatory action. This process, 
differing from ordinary inflammation in some particulars because 
of the varying physical character of the affected substance itself, 
as well as of its environments, will arise from the same causes as 
do inflammations of other tissues, and may be studied from the 
same standpoint. 

The initial point will undoubtedly be in the tissue or organ 
that is the immediate source of food supply, — the periosteum, the 
investing or lining membrane of the bone. Disorders of this tissue 
must affect the living portion of the bone. Inflammation of the 
periosteum, if the degenerative process continues, ends in stasis of 
the blood currents, thus cutting off nutrition, with the consequent 
deterioration of the living contents of the lacunae and canaliculi. 

7 his inflammation, or affection of the living portion of the bone, is 
that which we call osteitis, and it is usually the initial point of necrosed 
conditions. If the osteitis is relieved through the removal of the 
source of irritation and the re-establishment of nutrient currents, 
thai i- essentially the resolution spoken of in dealing with Inflam- 
mations. If it proceeds to the breaking down of tissue it will be 
caries (ir necrosis, the analogues respectively <>f suppuration and 
gangrene. 



I50 ORAL PATHOLOGY AND PRACTICE. 

Like all other inflammatory conditions, osteitis is the result of 
some irritant. This may be a traumatic lesion, the presence of 
pus or of a foreign body, or the interference with nutrition caused 
by some external impression manifested through the nervous sys- 
tem. Anything that would induce the inflammatory process in the 
soft tissues may in a less degree be provocative of osteitis in the 
hard. Probably there was never an acute pericementitis that did 
not induce a corresponding osteitis in the bony tissues in the imme- 
diate proximity. We know that an alveolar abscess causes a 
breaking down of the bone about the infected spot, and the forma- 
tion of a cavity of greater or less extent. We are also but too well 
aware that pus from an abscess sometimes infiltrates the bone, and 
will burrow to a considerable distance, forming secondary pockets 
and foci of infection, which sometimes make thorough sterilization 
very difficult. YYe know, too. that it takes considerable time to 
effect the complete healing of the pockets and cavities in the bone 
thus formed, and that until the embryonic or temporary tissue that 
is the result of the first reparative process shall have time to con- 
solidate and become permanent through further progressive 
changes, there is always danger that the metamorphosis will take 
upon itself a retrogressive state and the whole again break down. 

All these conditions go to demonstrate the fact that osteitis, to a 
greater or less degree, is always present in pericemental complica- 
tions, and that in the treatment of such conditions its existence 
should be taken into account and care taken that it be kept in 
check. 

Symptomatology and Treatment. 

The diagnosis of osteitis as a separate infection is not readily 
made, and principally depends upon other known degenerative 
processes. The existence of an abscess in the immediate neighbor- 
hood of any osseous tissue must inevitably induce it. The mere 
presence of pus and of the micro-organisms of suppuration are 
sufficiently irritating to provoke an inflammation of periosteum, 
and that necessarily implies more or less of osteitis. But aside 
from such recognizable complications the condition does not pre- 
sent sufficient of pathognomonic symptoms to enable the observer 
always to detect it in its earlier stages. It may often be inferred, 
and in some instances perhaps determined, by exclusion of all other 
functional disturbances, but the pathologist must mainly depend 
upon associated disorders for his complete diagnosis. 



CARIES OF BONE. 151 

The periosteal inflammation that is the cause of, or that 
accompanies it, will manifest itself by a red line, or red blotches 
upon the superincumbent tissues, provided they are not too thick, 
and this will be intensified if there is very much of osteitis present. 
But this cannot be depended upon as a certain diagnostic symptom, 
though it may be useful as an adjunct. 

The treatment of osteitis in its early stages should he abortive, 
and it will not materially differ from that laid down for the relief 
of inflammation in other tissues in the chapter (X.) devoted to 
that subject. Its presence once determined, every effort should be 
made to discover the source of irritation and to remove it. About 
the jaws this will most frequently be a diseased tooth, and when 
that is restored to a healthy state, unless the disorder shall have 
existed for some time or the lesions be unusually violent, the 
inflammation in the lacunae of the bone will subside with the rest. 
If, however, this is not the case, and the retrogression or degenera- 
tive action persists, it will result in either caries or necrosis of the 
bone; and these will be considered under their appropriate heads. 



CHAPTER XLI. 
CARIES OF BONE. 



This disease may be compared to suppuration or ulceration in 
soft tissues. It is the devitalization of bone, cell by cell, and its 
breaking down by a comparatively slow progression, rather than 
death in mass. It has its origin in perverted or interrupted nutri- 
tion, but the phenomena exhibited vary somewhat from those of 
necrosis. It may arise from local irritations, or it may be general 
and constitutional in its origin, as in the case of scrofulous subjects 
or those affected by the syphilitic virus. A frequent source of 
maxillary caries will be found in the diseased roots of teeth, which 
act as sources of irritation. Not infrequently, too, it is the result of 
excessive violence in dental operations. Long-continued wedging 
will be likely to induce a local osteitis so severe as to interfere with 
the nutrition of the thin septa of bone between the teeth, denude 
them of periosteum, and resull in a wasting caries which will 
destroy that portion of the alveolar process by slow disintegration. 

It will be comprehended that tins form of caries materially 



152 ORAL PATHOLOGY AXD PRACTICE. 

differs from that which is by surgeons usually denominated caries of 
the bone, both in its etiology and symptomatology. While it may 
be aggravated, or even induced, by cachetic conditions, it is not 
characterized by the substituted granulation tissue. It has its usual 
origin in a local rather than a constitutional irritant. It more 
resembles in its progression dental caries, but is quite distinct from 
the latter in many of its characteristics. This form of caries of the 
bone may be readily diagnosed, through careful examinations, by 
any one who is skilled in such matters or who has cultivated habits 
of close observation. Yet the earlier periods in these perversions 
are recognized by but few dentists, because their perceptions have 
not been sharpened by continual practice. Either they are not 
sufficiently instructed to know what to look for, or they do not 
extend their observations beyond the teeth themselves, and neglect 
everything save that which obviously demands mere mechanical or 
operative interference. Any localized congestion or inflammatory 
turgescence and swelling demands the attention of the practitioner. 
It may be indicative of a slight disturbance, or it may be the initial 
point of a serious lesion. The oral physician should be competent 
to determine which it is, and faithful enough to keep it under 
observation until it shall develop its true character; and the condi- 
tion should be recognized early enough to enable the practitioner 
to obviate the spontaneous formation of sinuses. 

True caries of bone will produce a marked change in the over- 
lying soft tissues. There will in the incipiency be great determina- 
tion of blood to the parts, with congestion and tumidity. This will 
gradually assume a deeper color, until it approaches a purple hue 
and sloughing commences. In simple denudation caries of the 
maxillary process there will be very little of this, nor will there be 
any very considerable formation of pus. But there will be limited 
sloughing of the superimposed tissues, with denudation of the bone, 
more or less complete, beneath. 

An opening through the soft tissues will be found, and this 
may be discharging a small amount of pus, though without acute 
complications. If now a probe — the best one for such cases is a 
hatchet-shaped excavator — or an explorer of some kind be carried 
through this opening, the bone will be found quite denuded and 
softened. The point of the excavator will readily enter it, and 
small spicula from the roughened surface may be readily chipped 
off. There will be none of the smooth, solid, resisting sensation 



CARIES OF BONE. 1 53 

that a healthy bone presents. To the educated sense of touch it 
presents characteristics that cannot well be mistaken. If there is 
ca.ies of the septum of the bone between the teeth, the result of 
traumatic violence, perhaps in filling, there will be a peculiarly 
rough, gritty feeling, showing that portions. of it have been thrown 
off, with destruction of the periosteum. There may be a distinct 
putrefactive odor from the diseased territory, showing that food is 
undergoing decomposition there, even if there is no appreciable 
formation of pus. 

The treatment of caries of the bone will be both local and 
general. If the degeneration is extensive, it will indicate a general 
debility that demands the use of tonics. If there are any acute 
symptoms, premonitory to a yet more rapid breaking down of 
•tissue, the most active abortive measures should be instituted, and 
cathartics, diaphoretics, counter-irritants, with local depletion by 
means of scarification, or leeches, or cupping, should be employed. 
As soon as these are effective in reducing the acute phenomena, 
or if the condition is ascertained before such active symptoms are 
manifested, the dead and carious bone should be burred away with 
the dental engine, and, if necessary, the diseased surface carefully 
curetted or scraped. This process must be carried to the extreme 
limits of the dead bone, which, unless there is a carious sinus, will 
not be very deep. 

This done, and all debris carefully washed away, the surface of 
the affected bone may be saturated with aromatic sulphuric acid, 
which may be allowed to act for a few minutes, when the cavity 
should be thoroughly washed with water. That an acid, especially 
sulphuric, will exercise a selective action, dissolving only dead tis- 
sue . seems to be proved by the experiments of the late Prof. J. E. 
Garretson, who caused to be submitted to the action of a twenty- 
five per cent, solution of sulphuric acid, for three days, fragments of 
dead, of diseased, and of healthy bone, with the result that in dead 
bone a considerable proportion of the lime salts was dissolved, in 
the diseased bone a less amount, while in the healthy bone no such 
action took place. Great care must subsequently be exercised to 
keep the territory clean and aseptic, disinfectants or antiseptics 

g used if necessary. 

If the tissues seem indolent, they may be stimulated to action 
by the use of a weak solution of the chlorid, or iodid of zinc. 
' opportunity must be given for the Formation of a new periosteum, 



154 ORAL PATHOLOGY AND PRACTICE. 

and when the reparative process is once under way the forming 
tissue must be left undisturbed, except for occasional gentle irriga- 
tions with an antiseptic or stimulative solution when that is abso- 
lutely necessary. Many practitioners defeat their own efforts by 
uncalled for and meddling interference, by over-treatment when all 
is progressing satisfactorily. 

The preceding remarks apply more directly to caries of the 
alveolar process of the jaws. In caries of other bones there is 
almost always some cachectic condition, such as tuberculosis or 
syphilis, which induces the carious degenerations. If there is 
infection by septic organisms suppuration of course ensues, and 
the disease may assume a more active necrotic type. In dry caries 
of the alveolar process, which is the form most frequently met with 
by the oral practitioner, there is nothing of this kind, nor is there 
necessarily a constitutional dyscrasia, the local irritation being 
sufficient to induce the gradual wasting of the cancellous bony 
tissue, through the gradually progressive cutting off of nutrition. 

In oral practice, then, a distinction may readily be 
made between the carious disintegrations of the alveolar 
process of the jaws, that may not be accompanied by any 
specially inflamed conditions and in which there are few 
if any traces of ulceration, and the porous, abscessed state 
of true caries, which is surrounded by foreign, unhealthy 
granulations of the soft tissues. The one is merely a gradual 
disintegration, brought about by the deprivation of the nutrient 
supply, with denudation of the process by sloughing of the perios- 
teum, while the other is the breaking down of osseous tissue with 
the formation of fetid pus, which tends to burrow into the tissue. 
The first is due to simple lack of nutrition, usually the result of 
some injury, while the other is a cachectic state arising from some 
constitutional disturbance, the tuberculous deposit being its most 
frequent accompaniment. 

The only treatment demanded by the progressive crumbling 
of the alveolar process will be to remove any irritating cause, bur 
out the bone that is denuded of its periosteal covering and that is 
disintegrating, and then, by the use of stimulating astringents, to 
induce a new membranous growth. 

If there is an ulcerative condition, due to a dyscrasia, constitu- 
tional treatment will be demanded, and this will consist in the pre- 
scribing of nutritious diet, cod-liver oil, hypophosphites, syrup 



NECROSIS. 155 

of iodid of iron, etc., with the local treatment previously recom- 
mended, and specific remedies when indicated. 



CHAPTER XLII. 

NECROSIS. 



Necrosis of the hard tissue is the analogue of gangrene in the 
soft. Its progress is not so rapid, because of the difference 
in the physical characteristics of the tissues themselves. But its 
origin is in an identical disturbance of nutrition, its course presents 
the same pathological changes, the termination is usually similar, 
and the treatment involves the consideration of cognate principles. 
Inflammation forms the initial point in its morbidity, and it is from 
that standpoint that the degenerate modifications should be 
studied. 

Necrosis differs from caries of the bone rather in degree than in 
essence. As gangrene is the death of soft tissues in mass, so 
necrosis is the devitalization of a territory having an osteogenetic 
origin. Like caries of bone, its cause may be either traumatic or 
specific, local or constitutional. It may attack any of the bones, 
but the maxillae are especially subject to it; necrosis of the lower 
jaw is four times as common as in the upper. In simple caries of 
the bone this proportion is nearly reversed. When not the result 
of an injury, its origin is in an inflammation of the investing or 
lining membrane, which spreads to the lacunas of the bone, thus 
producing osteitis, which eventually reaches the point of entire 
inhibition of nutrient currents, with subsequent death of a territory 
more or less extensive. 

Necrosis is usually an indication of a weak, anemic, or debili- 
tated condition. When all the functions of life are active and 
general nutrition is good, vitality in a part will be maintained 
despite unfavoring conditions. But when there are defects in the 
assimilative process retrogression is easy, ami there is a predis- 
] .< >- i t i( m to wasting diseases. The most fruitful source of necrosis 
<>t' tin- maxilla- will be found in the presence of decayed, diseased, 
irritating roots of teeth. These initiate inflammations, and exacer- 
bate them when once started, prevent nutrition, and hence provoke 
devitalization. When the suppuration of alveolar abscess takes 



I56 ORAL PATHOLOGY AND PRACTICE. 

place the pus may burrow beneath the periosteum of the bone, and, 
separating it, cut off nutrient currents from the territory beneath. 
This will be especially probable in the lower jaw, for drainage of its 
pus pockets is usually imperfect, while gravity constantly tends to 
bring about infiltration ; and this will in part account for the greater 
proportion of cases of necrosis in that bone. 

A fruitful cause for necrosis of the jaws will be found 
in impacted teeth, arising from the lack of room for their 
proper development. This is especially true of the third molars, 
the body of the jaw between the symphysis and the ascending 
ramus often being too short to afford room for all the teeth. When 
the time comes for the development and eruption of the wisdom 
tooth all the space is occupied; it is imbedded in the tissues with- 
out power to advance, and becomes a source of violent irrita- 
tion. An inflammation is excited which assumes a peculiarly 
vicious character, and, the irritant still remaining, there is breaking 
down of tissue, infection, and suppuration. In the general degen- 
erative state this spreads to the bone, with consequent acute osteitis 
and necrosis. This condition, to which the upper jaw is not as 
liable, yet further accounts for the disparity in the relative number 
of cases in the two jaws. 

Necrosis may also be the result of injuries done by the 
dentist. Fractures of the alveolus in extraction are very com- 
mon, but such is the recuperative power of these very vascular 
bones that nature usually buries the faults of the incompetent or 
reckless operator beneath new formations. If, however, the 
patient is suffering from any form of atony, the reparative process 
may not be sufficiently active to restore the normal condition, and 
retrogression may take the place of progression. In such patients 
the mere careless puncture of the alveolus to some depth by a 
sharp-pointed excavator, or plugger, or engine bur that has been 
infected by some septic product may induce a septicemia that will 
result in serious necrotic complications. Arsenous acid, when 
used in too great quantity for the devitalization of a tooth pulp, or 
if not securely sealed in the cavity of decay, may penetrate to the 
alveolus and produce a necrotic condition that will spread to other 
tissues. 

Many zymotic and exanthematous diseases sometimes 
have necrosed conditions among their sequelae. This is 
especially true of scarlet fever. Mercury, when given in large 



NECROSIS. 157 

doses, may cause it. Syphilis is quite likely to attack the palate 
and nasal bones. People who, having dead teeth, work in match 
factories, are especially liable to a form of affection called phosphor- 
necrosis, caused by the fumes of the phosphorus used, which is 
supposed to penetrate through the root canal, and thus to come in 
contact with the pericementum which gives nutriment to the 
alveolar sockets. So universally is this special condition recog- 
nized, that in France every factory that uses phosphorus in the 
manufacture of matches must employ a dentist, whose duty it is 
periodically to examine all the inmates and forbid the employment 
of any that have dead teeth with unfilled roots. 

The diagnostic signs of necrosis are usually distinct and well 
marked. With the death of the bone, the overlying tissues with 
which it is invested become peculiarly turgid and inflamed. They 
finally assume a characteristic purple tint, and look exceedingly 
angry. This is increased as the tissue commences to break down 
beneath the surface, and suppuration ensues. There is little of the 
characteristic "pointing" of alveolar abscess, but the pus finds its 
way to the surface at a number of places, and the discharge is 
usually profuse and fetid. If now an explorer is passed into one of 
the sinuses until it reaches the bottom, the characteristic sensation 
imparted by dead bone will be plainly felt; or if the disease has been 
peculiarly active in its character deep cavities may be detected in 
the bone, with crumbling, disintegrating edges. Minute chips of 
the degenerated bone may be easily separated with any appropriate 
instrument. There will be the usual septic fever, and this may be 
decidedly pronounced. There will be a general malaise and loss 
of strength and vitality. 

The constant tendency on the part of nature is to get rid of the 
dead and irritating tissue. The very suppuration that accompanies 
all necrosed conditions is a part of this process. It is indicative of 
a disposition to slough away the diseased portion. Sometimes this 
i- successful. There is a clear line of demarcation drawn between 
the dead and the living tissue, and the granular lymph acts as a 
kind of wedge to separate them. If this is accomplished, the dead 
part that is thrown off is called the sequestrum. At the same time 
there will perhaps be a successful effort on the part of nature to 
reproduce the bone, and this may be outside of and envelop bhi 
sequestrum. Such new enveloping bone is called the involucrum, 
and it may entirely prevent the exfoliation of the sequestrum. 



I50 ORAL PATHOLOGY AND PRACTICE. 

When there is extensive alveolar necrosis of a peculiarly active 
type it is not always judicious to extract teeth, even though they 
are plainly involved. There is a difference of opinion upon this 
point among pathologists, but it must be evident to all that if the 
disease is the result of an acute osteitis, and the attachment of any 
part of a tooth is in live bone, its extraction will produce a wound 
that will be certain of infection; the inflammation will spread and a 
new focus will have been produced, which might have been avoided 
had the tooth been left to the slower process of exfoliation. On 
the other hand, if the tooth is a distinct irritant that is aggravating 
the situation it should be removed, provided it may safely be done. 
It will therefore be seen that it sometimes requires the nicest dis- 
crimination to determine this point. 

If there is a tendency toward the formation of a sequestrum, 
tne dentist naturally desires to hasten this process. But here again 
good judgment must be employed. If it is violently torn away 
before the separation of the dead from the living tissue is completed 
by nature an open wound is produced, as in the case of extraction 
of a tooth; and at this point, minute though it may be, inflammation 
may begin anew and the diseased state thus be aggravated. But 
when a fissure of separation can be felt, a pledget c: antiseptic cot- 
ton or gauze may be crowded in, and thus a little pressure made to 
assist the process of exfoliation. 



CHAPTER XLIII. 
TREATMENT OF NECROSIS. 



The treatment of necrosed conditions may he divided into three 
parts, — local, operative, and general. The first will consist of the 
use of disinfectants and depurators. There will be little occasion 
for antiseptics, because the flow of pus cannot be prevented as long 
as there is dead bone. But the whole diseased territory should be 
kept as carefully drained as possible, and it should be frequently 
and effectually cleansed with some good disinfectant. For this 
purpose electrozone, or meditrina, will be found especially useful, or 
peroxid of hydrogen, or a three per cent, solution of pyrozone 
may be injected with a syringe or applied with an atomizer. If 



TREATMENT OF NECROSIS. 159 

the discharge of pus is into the mouth, that cavity should be fre- 
quently washed with an antiseptic gargle, and as much care as pos- 
sible should be exercised to avoid swallowing the septic products. 
A drainage tube, or strip of iodoform gauze to serve as such, may 
be introduced into the sinus if its location is such as to demand it, 
and this may be held in place, if necessary, with strips of adhesive 
plaster. Of course, neither of these will be appropriate if the dis- 
charge is within the oral cavity. 

Sulphuric acid may, in some instances, be profitably employed 
to dissolve out the dead bone. It may be used in such strength as 
the nature of the case demands, from a dilute aromatic solution to 
the chemically pure. Of course the latter will only be employed 
with caution. There is no danger to the soft tissues involved, 
unless possibly from the chemically pure, and even that involves 
no serious effect if it is properly used and washed away in time. 
Local stimulants may be employed to overcome the indolence if 
necessary. 

The operative measures to be employed will consist of 
those necessary to secure perfect drainage, and operations 
for the removal of the dead bone. Sometimes in the lower 
jaw a deep pocket will be formed in the body of that bone, through 
the enlargement by necrosis of the socket of a tooth which was the 
original cause of irritation. Drainage of this may be impossible, 
through the inability of the tissues to expel the pus over the 
borders. 

In one such case the author, against his own better judgment 
but at the solicitation of both the patient and the dentist who had 
referred her to him, attempted in vain the acid treatment after thor- 
ough burring out of the necrosed cavity. The pocket could not be 
kept clean, and reinfection from the retained pus was certain, 
until an anesthetic was given and an opening made from outside 
the face and beneath the jaw into the cavity. A strip of iodoform 
gauze was then passed through into the mouth, drawn back and 
forth repeatedly, ami the end finally left projecting from the 
external wound to assist in drainage. The result was a speedy and 
complete cure, without the use (if any other agents. In some cases 
<>! necrosis of the upper jaw, operative measures may be necessary 
to open completely and straighten out the sinus of discharge. This 

may he readily done by a proper bur in the dental engine. 

The operation for the complete removal of dead bone 



l60 ORAL PATHOLOGY AND PRACTICE. 

in the maxillae may be of a formidable character, and its 
consideration may properly belong to the domain of oral sur- 
gery. It must be thoroughly done, if done at all. Half-way op- 
erative measures are of little account. The patiem, having been 
properly fortified with nourishing food for a time, is anesthetized 
and placed in such a position as will afford complete command of 
the situation. The superincumbent tissues are laid back by the 
proper incisions, the blood checked by ligatures or the use of 
hemostatic forceps, and the territory carefully sponged and exam- 
ined. When the extent of the lesion is fully determined, the proper 
steps are taken for the removal of the dead and diseased bone by 
the use of the dental engine, bone chisels, scrapers, and saws. 
When this is completed, all exposed edges of bone must be made 
smooth, every particle of debris removed, and the wound antisepti- 
cally washed and properly closed, with sutures if necessary, a drain- 
age tube inserted, the exterior dusted with iodoform powder, and 
the whole enveloped in the proper bandages and dressings. If 
the wound is wholly within the oral cavity, of course the iodoform 
dusting and the bandaging will not be called for. The desirability 
of working within the mouth when practicable cannot be too 
strongly urged, especially in the case of young women, that dis- 
figurement may not be the result; but the success of an operation 
should not be jeoparded in the effort to avoid minor disfigurement. 
A visible scar is better than death, or even the entire loss of a bone. 

General or systemic treatment is called for in almost every case 
of extensive necrosis. The disease is of such a wasting nature that, 
at the very least, tonics and a sustaining diet will be called for. 
The patient should be made to live out of doors as much as pos- 
sible, and every hygienic precaution be taken. If the lesion is the 
result of some cachectic condition, like syphilis or mercurialization, 
the general treatment proper to such condition must be instituted. 
For the former a strict course of specific treatment will be de- 
manded. The subject is presented in another chapter, and hence 
it is not necessary to pursue it farther in this connection. 

The tonics that are used in wasting diseases are of two kinds, — 
vegetable and mineral. The former consist mainly of the bitter 
barks of certain trees, while the latter are inorganic substances that 
exercise a peculiarly stimulant or alterant action that tends to pre- 
vent waste or assist nutrition. Of the vegetable tonics, Peruvian 
bark or cinchona, quassia, gentian, and wild cherry, with their alka- 



HYPERSENSITIVE DENTIN. l6l 

loids, are those most commonly employed; while the inorganic or 
mineral agents most used are preparations of iron, of copper, and 
of zinc, with such other remedies as subnitrate of bismuth and sul- 
phuric, nitric, hydrochloric, and oxalic acids. 



CHAPTER XLIV. 
HYPERSENSITIVE DENTIN. 



Were it possible to rob operative dentistry of the horrors too 
often its determined attendant in the pain and anguish that excava- 
tion of carious teeth causes, public health would be greatly con- 
-served and human life would be correspondingly lengthened, be- 
cause of the greater care that would be bestowed upon those 
organs. Would the public generally learn to look upon the dentist 
in his true light, — that of one whose mission it is to avert pain and 
suffering, — he would be regarded with much greater favor and 
would enjoy higher consideration. But the nature of his work is 
such that, like the general surgeon, in his efforts to forestall future 
anguish he too often brings present distress, and too many who 
should be his patients choose to postpone the evil day and hazard 
all the future rather than risk a moment of the present. 

Recognizing all this, dentists from the earliest period in the 
history of their art have been constantly striving to devise some- 
thing that will give exemption from pain in dental operations. 
Most of their efforts have been entirely empirical, and their experi- 
ments and labors have been conducted in a haphazard way that 
betokens anything but professional erudition or scientific knowl- 
edge. Those who have claimed to accomplish anything in the way 
of a solution of the problem, have not usually been those who were 
best equipped by education and professional attainments for the 
task. The practitioner who advertises "painless dentistry" has 
passed into a byword, and the term is a synonym for an impostor 
and ;i charlatan. Almost invariably those who have brawlingly 
boasted that they have discovered a universal panacea for all dental 
pain have been illiterate, undisciplined, unknown pretenders, whose 
sole object was to secure a dirty dollar by unprofessional methods, 
and to make profit out of that which should be public philanthropy; 

men who would, if possible, garner the SUn's 1. earns and peddle 

12 



l62 ORAL PATHOLOGY AND PRACTICE. 

them out for individual gain; who would put holy things to an 
unholy use, and make of human benevolence a public prostitute. 
Of this character have been most of the widely advertised prepara- 
tions for the obtunding of the dental tissues, — quack remedies, pre- 
pared by dental quacks for quackish purposes. The student and 
practitioner should avoid them if he is an honest man, for he has 
no moral right to recommend to a patient, who pays him for special 
knowledge, any drug of whose exact nature and therapeutic value 
both are alike ignorant. 

In its normal condition dentin should be without sensation. 
There are no organized nerves to convey impressions, even were the 
tooth-bone subject to them. Yet the protoplasmic, albuminoid con- 
tents of the dental tubuli may, under special irritation, become 
the subjects of inflammatory conditions, in which they not only re- 
ceive, but readily transmit to the dental pulp, external impulses 
of a painful nature. It is true that the pulp of the tooth is supplied 
with nerves; yet they are without some of the characteristics of 
ordinary nerves, and, protected from all irritating shocks as it is in 
its normal state, even the pulp is not of itself responsive. Only 
when some of its protection is withdrawn, or when from some 
reflex source the pulp is subjected to external irritation, does it 
become impressible to outward agencies and convey disagreeable 
sensations. 

We know that it is a law that animals, and organs and tissues, 
adapt themselves to their environments and change their structure 
with varying conditions. Thus the fishes of rayless caverns lose 
their sight, and certain inhabitants of the greatest ocean depths are 
without the usual sensory functions. Both, by gradual transmis- 
sion to other surroundings, would develop special senses, as have 
other organisms. Continual subjection to external irritation may 
either weaken or develop the corresponding sentient perceptive- 
ness, through which alone can defense and security be obtained. 

That both dentin and dentinal pulp are without ordi- 
nary sensation when in a perfectly healthy and normal 
condition, is proved by the fact that when a healthy tooth 
is fractured and the pulp thereby completely exposed, it is 
irresponsive to external irritants for a short time. Healthy 
pulps are painlessly "knocked out" by a certain class of practi- 
tioners, provided the teeth are sound and the work is done quickly 
enough. But if there is the least inflammation in either pulp or 



HYPERSENSITIVE DENTIN. 163 

dentinal fibrils the operation is anything but painless. ' There is 
not a practitioner who has not at some time cut into the dental 
pulp entirely without the knowledge of his patient, provided he 
was excavating in dentin that was completely or even compara- 
tively irresponsive. 

The source of sensitive dentin, or of impressionable pulps, lies 
in their continued subjection to irritation, by which responsiveness 
is developed. The freshly exposed pulp, or dentin, of a perfectly 
healthy tooth is without sensation. But a few moments of subjec- 
tion to external influences, the air and other irritants, are sufficient 
to produce a marked change in the tissues, and they become 
exquisitely responsive. A kind of inflammatory degeneration 
takes place, and normal function is so altered that disagreeable 
currents are conveyed. This is in perfect harmony with the other 
known processes of Nature, for in the presence of danger she 
always develops means of defense by giving warning through the 
awakened senses. 

If, then, in the normal state the tooth tissues are without 
sensation, it follows that if a pathological condition is succeeded 
by one of perfect health, the immunity to pain should be re-estab- 
lished. This is undoubtedly the fact, for teeth that have been 
attacked by caries, and which under its influence have become 
painfully sensitive, have, when the broken continuity has been 
restored by a filling, lost that responsiveness and again became 
eptible to external impression. It is true that this is not 
always the case, because the very material that has been used to 
mend the broken place may of itself become an irritant and per- 
petuate the abnormal state. Were it possible to fill an ordinary 
tooth with something that would be perfectly congenial to the 
tissues, there is little doubt that all filled teeth would be comfort- 
able, and herein may be found a reason why certain materials, 
aside from their lasting qualities, make the best fillings. 

The test for the perfect success of an operation is the condition 
of the tissues which ensues, — because decay is not the first 
symptom of the failure of an operation. It may be found in the 
responsiveness of the dentin to external irritants; to its sensitive- 
ness to outward impressions. Nol that it is always possible com- 
pletely to restore to healthy functional activity a tooth that has 
been subjected t<> operative filling. Usually only toleration with 
mild protesl ran be obtained for the foreign matter thai is used 



164 ORAL PATHOLOGY AND PRACTICE. 

for protective purposes, especially if it is of a metallic nature. 
When there is permanent denudation of any part, as in recession 
of the gums, normal conditions cannot even be approximated. 

One of the causes of the irritation in which is found 
the source of sensitive dentin is caries. This is of itself a 
pathological condition of dentin, and its progress necessarily 
entails other degenerative conditions. The disintegration of por- 
tions of the tooth-bone, with the consequent destruction of parts 
of the dental fibrillar, must affect that with which it is in connection; 
and so there will be an irritable, disordered condition of the whole 
of the dentin, with hypersensitiveness and inflammation of the 
protoplasmic elements of the soft fibrils, modified in manifestation 
by the character of the structure itself. With such a destructive, 
deadly disorder as caries working at its vitals, no portion of the 
structure of a tooth can be in a healthy state, for although teeth 
have not the complex and vascular formation of the soft tissues, 
we cannot consider these organs as made up of dead, inert matter. 

Denudation of portions of the tooth, its loss of a part 
of that which should form any of its investing protection, 
must subject it to unnatural conditions. If the gum has 
receded at the neck, that simply means that the tooth is exposed to 
new environments and strange perplexities that cannot be other- 
wise than exasperating. Under the stress of their provocation it 
assumes an added susceptibility, and becomes more and more 
liable to attacks of external agents. All the dentin is thus affected, 
and it becomes tender, sensitive, responsive to any provocation. 
This, as in the case of caries, proceeds by continuity of tissue to 
the pulp, which also becomes irritable and inflamed, so that there 
is an immediate response to thermal changes, to the presence of 
acids or sweets, and even to the finger nail or quill toothpick. 
Metal toothpicks are almost always irritating to the teeth. 

Vitiated secretions are also a cause of sensitive dentin. 
That of the somewhat specialized mucous follicles at the gingival 
margin, through neglect of the teeth and the presence of fermenting 
debris, is sometimes of a degenerative type. This secretion becomes 
acid, and in this state is highly irritative to the cervix of the tooth. 
Or the white deposit which is so frequently found surrounding the 
tooth at its neck, and which is made up of decomposing matter 
undergoing fermentation or putrefaction, may be the cause of the 
irritation. The resulting acid may dissolve out some of the lime 



TREATMENT OF HYPERSENSITIVE DENTIN. 165 

salts at the cervix, where the enamel is very thin, and so lay bare 
the dentin, which will thus be made specially irritable. Some of 
the most sensitive dentin encountered by the operator is the result 
of this acid degeneration or formation. 

The teeth are sometimes set on edge by the use of 
acids. This means softening of the superficial portion of the 
tooth, and a hyperesthesia, or its analogue, of the dentin. The 
sensation referred to is not a distinct pain, and it usually passes 
away with the provocation, but it is a definite feeling of responsive- 
ness in dentin. The same kind of impression may be induced by 
reflex action, when a saw is filed or strong- cloth is torn. 



CHAPTER XLV. 
TREATMENT OF HYPERSENSITIVE DENTIN. 

It has been affirmed that if a tooth that is in a healthy condi- 
tion is insensible, a return to that state after diseased action should 
carry with it freedom from responsiveness. While this may be 
true, it is not always possible in dental practice to secure this result. 
In cases of caries it is impossible to induce a healthy state except 
by excision of the diseased part, as in necrosis of bone; and it is 
from the pain of that operation that we seek immunity, hence the 
only hope of the dentist is in securing an artificial anesthesia of the 
part. This may be readily accomplished, as in the other tissues, by 
inhibiting and stopping all nervous currents through general anes- 
thesia. But such methods are prohibited by the circumstances of 
the case. We do not wish to obtund all sensibility, but onlj to 
overcome that of a small part. 

The ordinary local anesthetics might be employed, and they 
would completely answer all demands were that which we wish to 
make insensitive supplied with blood vessels and nerves. Unfor- 
tunately For our object, this is not the case with the teeth. Theirs 
is not the structure upon which anesthetics act, and hence the latter 
are of but doubtful utility. Winn cocain was first discovered it 
was believed by man} thai the dental millennium had surely 
arrived, bul thai agenl has been found powerless to benumb non- 
vascular tissues. This class i >f remedies may therefore be dismissed 
from consideration, because while they ma) under certain condi- 



l66 ORAL PATHOLOGY AND PRACTICE. 

tions inhibit nervous currents in tissues that have a nervous supply, 
they are inefficacious when that is lacking. Cocain will obtund a 
pulp that is exposed to its influence, but it is ordinarily powerless 
upon dentin. 

We are thus obliged to fall back upon specific remedies, or 
those whose therapeutic action is not thus limited. We know that 
the protoplasmic dentinal fibrils, when in an irritable state, or when 
made responsive by certain pathological conditions, will convey 
painful impulses along their course and deliver them to the 
terminal nerve filaments of a more or less inflamed pulp. If, now, 
these afferent waves of irritation can be cut off at any point before 
reaching the sentient centers, immunity from pain will thereby be 
secured. This can be done by a general anesthetic that paralyzes 
sensory filaments and trunks, or it could be accomplished by the 
application of a local anesthetic directly to the pulp itself. Both of 
these, for reasons already given, are impracticable, and it leaves the 
work to be done upon the only other connecting link between the 
dentinal periphery and the brain. 

If the dental fibrils themselves can be put in such a state that 
they will no longer carry impulses to the pulp, that tissue cannot 
transmit any to the afferent nerves which carry them to the nerve 
centers. 

There are two ways of accomplishing this, neither of which is 
entirely satisfactory in its results. The first is by producing some 
temporary physical change in the character of the fibril that will 
prevent its receiving an impulse, and the second by subjecting it to 
some medicinal agent that will paralyze its transmitting function. 

There are perhaps two other methods of accomplishing the 
same thing which should be included in the list of methods to be 
employed, and they will be duly considered. They are, first, the 
exercise of such care and gentleness, with the use of such perfected 
instruments as shall arouse no irritating pain waves; and, second, 
the employment of such general prophylactic remedies and 
measures as will so fortify the system as to enable it to resist them, 
or steel it against their reception. 

The physical agents which are practicable will be such 
as will temporarily change the material characteristics of 
the fibrillae, and of these the most important are heat and 
cold. 

Heat may act either by raising the temperature above the point 



TREATMENT OF HYPERSENSITIVE DENTIN. 1 67 

of susceptibility, — which is impracticable because it is of itself a 
painful process, — or by so changing the matter of the fibrillar 
through desiccation, or drying out, as to make them incapable of 
conveying impulses. It is readily conceivable that, a cavity being 
isolated by the use of a rubber-dam, a current of hot air may be 
effectual in so changing the physical structure of a fibril, by 
abstracting a part of its water, as to debar all reception or trans- 
mission of nervous or other impulses. This is perhaps the most 
simple of all methods for obtunding sensitive dentin. 

The use of cold, or refrigeration, will be equally effectual by 
benumbing or paralyzing the fibrillse. If an ether or rhigolene 
spray is directed upon the tooth cavity, or even upon the tooth 
itself, until the temperature is reduced sufficiently, it will be com- 
paratively irresponsive. This would without doubt be the most 
perfect obtundent, were it not that the effective use of the agent 
is of itself too painful in its application. There is also danger that 
the pulp tissue may be permanently injured through degenerative 
processes inaugurated by the shock of the cold. A severe inflam- 
mation may be the result of the application of the ether spray for 
too long a time. Hence this has never been widely used for 
obtunding purposes, except in extreme instances. 

The medicinal agents that have been employed in the 
overcoming of dentinal hypersensitiveness are almost 
numberless. General and local anesthetics, stimulants and 
anodynes, excitants and sedatives, acids and alkalies, with many 
drugs of altogether indefinite and unknown therapeutic value, 
have been persistently recommended. The whole matter has 
generally been one of empiricism. It would seem that, so far as 
our present knowledge goes, anesthetics, whether local or general, 
have little direct effect upon dentinal tissue. All such remedies 
have a selective power, and affect nervous tissue alone. The den- 
tinal fibrillar, while they do not contain any nervous filaments, yet 
comprise the elements of such tissue; and it cannot be positively 
affirmed that they are not, under certain conditions, amenable to 
anesthetic action. But we kn<>\\ thai they are not ordinarily so, 
and hence the agents referred to have proved as inefficient as might 
have been anticipated. 

Certain sedatives, anodynes, and narcotics, like prep- 
arations of opium, cannabis indica, and chloral hydrate, 
have been effective in certain instances, but it is not at all 



1 68 ORAL PATHOLOGY AND PRACTICE. 

certain that they did not work through other tissues, and 
thus act indirectly instead of directly. Some cauterants are 
effectual, but to a limited depth. Thus nitrate of silver, or chromic 
acid, or carbolic acid, will obtund, but only to the limited depth to 
which they reach. They certainly destroy the fibrillas completely 
as far as their action extends, but that action is not really obtund- 
ing, it is extinction. 

In the harmless coagulation of 'the albuminoid contents of the 
dental tubuli would seem to lie the surest road to success. 

There are coagulating agents that thus obtund, like chlorid 
of zinc, but it is too often at the expense of quite as much suffering 
as tbey save, leaving out of consideration the dangers to which 
the dental pulp is exposed by the use in its proximity of active 
escharotics. If coagulation could be accomplished without per- 
manent injury to the tooth structure, and would reach deep 
enough to allow of effective excavation, the agent that accom- 
plished this without pain would be the long-sought desideratum. 
That drug has not yet been discovered, nor can we be sure Jihat it 
ever will be. Certain it is that until it is sought for in an intelli- 
gent, scientific manner, it will remain a secret; for the illiterate, 
untaught ignoramuses who have in the past been mainly respon- 
sible for the quack preparations sold at an extortionate price, and 
who have not the pharmacal knowledge to save them from com- 
pounding the most glaring chemical incompatibles, are not likely 
to be the discoverers of that which so many competent men have 
sought in vain. 

Cataphoresis, which is the transfer of medicaments 
into the deeper parts of tissue through the diffusive power 
of an electric current, seems to promise something in this 
direction. It is not recently acquired information that has 
taught us that when a drug is applied to a tissue upon the posi- 
tive electrode of a battery, the negative being placed so that the 
current will traverse the organ to be affected, it will carry with 
it the remedy; this principle has been quite extensively employed 
in general medicine, and with good results. To make the remedy 
in cataphoric medication effective it is not sufficient to carry it 
deeply into the dentin; it must be transferred to the pulp itself, 
and to the accomplishment of this the hard dental tissues present 
difficulties not met with in other organs, in their relatively low 
vitality and their comparative impenetrability. Yet practical 



TREATMENT OF HYPERSENSITIVE DENTIN. 169 

experience seems to point to the indisputable fact that cataphoric 
transference does take place, but whether with sufficient readiness 
and rapidity to make it all that can be desired remains to be 
definitely established. No one will dispute the assertion that in 
the cataphoric transference of such topically applied remedies as 
cocain and morphin better results have been secured than in any 
other of the thousand proffered methods of obtunding sensitive 
dentin. But its employment requires a cumbersome and expen- 
sive apparatus, troublesome alike to operator and patient, and its 
results are by no means uniform. While, therefore, every progres- 
sive operator should use it, it is not now to be considered a finality. 
Its application must be simplified and its effects made positive by 
further experimentation before it can be so accepted. Good men 
are investigating it, and it is to be hoped that in it will eventually 
be found that which is so highly desirable. It cannot be forgotten, 
however, that good men have before this cried, "Lo, here! Lo, 
there!" only to meet final disappointment and defeat. 

Prophylactics have proved of great service in the den- 
tal operating room. They are of sedative nature, and reduce 
general nervous irritability, thus preventing or obtunding nervous 
shock. These have not been as much used as their merits demand, 
because most dentists have either been lacking in the medical 
knowledge necessary to their most intelligent use, or have not 
felt themselves warranted in administering general remedies. The 
first of these causes, if it exists, should be at once removed by 
study, and the last eliminated by a proper amount of self-confi- 
dence. The time for administering such remedies is a few 
moments before commencing any painful operation, the exact 
interval depending upon the nature of the drug. A few whiffs of 
chloroform or ether, not enough to induce any functional dis- 
turbance whatever, will frequently be of use, but their influence 
will not last long. Twenty-five grains of potassium bromid in 
water will be more persistent, and usually quite as effective. 
Syrup of lactucarium, in teaspoonful doses, has been employed with 
good effect; or tincture of belladonna, administering from five to 
twenty drops. 

Sulphate of morphin, in d< ises of fr< »m a quarter to half a grain, 
lias been Frequently used, but its action upon some people is a little 
uncertain. The- fluid extract of Jamaica dogwood may be substi- 
tuted for this, and five to twenty drops given in a little water. 



I/O ORAL PATHOLOGY AND PRACTICE. 

The full dose of the drug is from a half to two fiuidrams. The 
author has not for several years been without aromatic spirits of 
ammonia in his case, and whenever there is unusual nervous irrita- 
bility he administers from forty to sixty drops of it in water. If 
there arises the necessity, a hypodermic dose of from one-eighth to 
a quarter of a grain of morphin may be given. This is usually 
effectual in quieting all nervous excitability and making otherwise 
insupportable operations comparatively tolerable. The proper 
dose of this drug, combined with atropin or strychnin, may be 
readily obtained in tablet form, and should always be kept at hand. 
Hypodermic medication has not been as much employed in 
oral practice in the past as it should have been. 

But, when all is said and done, the main dependence of the 
judicious dentist will be upon a gentle hand and sharp instruments. 
It is barbarous to employ in a sensitive tooth any tool that is not 
in the best possible order; while the operative dentist who for a 
moment allows himself to forget the consideration that is due to a 
sensitive, timid, shrinking patient, ^'ho will become in the least 
degree careless or callous, and thus give unnecessary pain, is 
unworthy his vocation. In excavating a sensitive tooth he should 
invariably put on the rubber-dam, and dry out the cavity as far as 
possible. Then he will find a great deal of relief in the employ- 
ment of many of the remedies already mentioned, and especially 
in the use of some of the essential oils, like cassia, cloves, or 
eucalyptus, securing penetration by means of the hot-air blast. 
A mixture of equal parts of sulphate of morphin and gum camphor 
may be found useful for this purpose in some instances. Or he 
may apply tincture of aconite dilute, or any other favorite remedy, 
always remembering that its effectiveness will be greatly increased 
by thoroughly drying the cavity of decay, and by the hot-air 
current. 

For those who wish a cocain preparation that is effective, the 
following is given. It should not be forgotten that this is a ten 
per cent, solution, and when used hypodermically less of it should 
be injected: 

R- — Atropin. j\ grain; 

Strophanthin, */s " 

Cocain mur., 50 " 

Carbolic acid, 10 

Oil of caryophyllus, 3 minims. 

Dist. water, 1 ounce. 



SECONDARY DENTIN, PULP NODULES, ETC. 171 

The following formula has been recommended by Professor 
Peirce as effective: 



It- 


-Cocain mur., 


5 grains; 




Carbolic acid, 


20 " 




Chloroform, 


x / 2 dram; 




Muriatic acid. 


10 minims; 




Alcohol, 


2 drams. 



CHAPTER XLVI. 

SECONDARY DENTIN, PULP NODULES, AND 
CALCIFICATIONS. 

These, although different manifestations, are parts of the same 
process. They have their origin in the same disturbed function. 
They are the result of deranged neural currents and of some per- 
version of nutrition which induces a formation of dentin in abnor- 
mal quantities or in an anomalous position, through the undue 
activity of the odontoblast cells under the excitement of just 
enough of irritation to act as the proper stimulant. All of these 
products have the general structure of dentin, although it may be 
considerably modified. They are not usually found as mere calcific, 
structureless calculi, but are organized by the unduly excited 
odontoblast cells, whose normal activity continues through life. 

The odontoblasts are not found exclusively upon the periphery 
of the dental pulp, any more than osteoblasts exist alone in con- 
nection with periosteum. The latter may be found within the body 
of the bone, and may be the initial points for new growths after 
operations or accidents. The former may exist enveloped in the 
pulp tissue, and under the special stimulus that was perhaps 
responsible For their formation, may commence functional activity, 
with the consequent organization of segregated spicules of dentin; 
and these may continue to grow until they assume the form of the 
usual pulp nodule. Sometimes this form of calcification may 
begin at many points within the pulp, and may impart to that of a 
freshly extracted tooth a gritty, sandy sensation when it is rubbed 

between the finger and the thumb. At other times there is an 

agglomeration into one or more large concretions. 

When the unwonted functional activity is at the peripheral 
pulp borders, the new formation will probably be attached to and 



I72 ORAL PATHOLOGY AND PRACTICE. 

form a kind of hypertrophy of the ordinary dentin of the tooth. 

Sometimes this will be so continued that it will almost entirely fill 
tip the pulp chamber, and even extend down into the root canal. 
An examination of an extracted tooth affected with this condition 
will show by its complete or partial attachment to the normal 
dentin, or by its independence of it, where was the commencement 
of the new growth. 

The "pulp stones," or formations of dentin that take place 
within the substance of the pulp, sometimes contain chambers not 
unlike the "interglobular spaces" of the tooth. These impart an 
appearance of bone, and the new formation is analogous to true 
"osteo-dentin." It may even have open canals that cause it to 
assume the appearance of vaso-dentin. As might be inferred from 
the circumstances under which it is deposited, its structure will be 
quite irregular and unmethodical. The canaliculi, or dentinal 
tubuli, will be involved, complicated, and irregular. There will 
be hyaline spaces, but the structure, when carefully studied, will be 
found to be essentially dentinal. 

The study of comparative dental anatomy will materially 
assist in a comprehension of these anomalies. In certain animals 
secondary dentin, or tooth-bone, is very common. This is 
especially the case with some of the monophyodonts. The per- 
sistent pulp chambers of the sperm whale (Physeter macrocepJialus) 
are very frequently lined or partially filled with secondary 
dentinal formations, and some of them make very beautiful objects 
when polished. The long incisors of the elephant, the so-called 
tusks, are frequently wounded by the hunter near their insertion, 
the bullets remaining in the persistent pulps. This may result in 
the destruction of the vascular portion of the tooth, but much 
more frequently the consequence is the deposition about the wound 
of secondary dentin, which perhaps will entirely inclose and 
segregate the original cause of irritation, and form septa across the 
pulp chamber. With the continuous growth of the tooth or tusk 
this is carried forward, until, perhaps many years subsequently, 
when the animal is killed and its tusk falls into the hands of the 
ivory cutters, the original bullet, with the secondary formation 
about it, is found in the solid ivory, perhaps two or three feet from 
the skull. 

Nature sometimes throws out a layer of secondary dentin to 
protect the pulp from slowly advancing caries, or erosion. The 



SECONDARY DENTIN, 'PULP NODULES, ETC. 173 

formative cells at the periphery of the threatened portion of the 
pulp are by the irritation stimulated to increased functional 
activity, and a kind of hypertrophy of dentin is the result. Prac- 
titioners have sometimes seen this take place under a plastic filling 
that had been inserted over a nearly exposed pulp. In the course 
of a few years this perhaps became sufficient support for a solidly 
impacted metal filling. This is the result hoped for in all instances 
of ordinary capping. Fractured teeth have been known to be 
united by a secondary growth of dentin, though these instances 
are probably few in number. 

The formation of so-called pulp stones and secondary 
dentin is a much more common occurrence than is usually 
imagined. The examinations of the pulp chambers of extracted 
teeth in the teaching of operative technics in some of the colleges, 
shows that a considerable proportion of teeth are thus affected. 
Prof. A. P. Southwick believes that from sixty to seventy per cent, 
of extracted teeth show some form of it, but as this applies only to 
such as have been extracted for diseased conditions, probably it 
would not hold good universally. 

The formations within the pulp chamber are some- 
times the cause of considerable local irritation, but neither 
the objective nor the subjective symptoms of these condi- 
tions are sufficiently distinctive to afford reliable means of 
diagnosis. When they are of rapid growth the pain may be of an 
acute character, but they do not under ordinary circumstances 
induce any breaking down of pulp tissue; nor do they bring about 
any serious complications. Usually the suffering is of that sub- 
acute nature that is hardest to locate. It presents no special dis- 
tinguishing characteristics, and a diagnosis can only be safely 
made through exclusion. When it is certain that the pain arises 
from nothing else, it may be attributed to secondary formations. 
It might, by the superficial observer, readily be mistaken for facial 
neuralgia, but it is not, like that, paroxysmal or periodical. Nor 
is it so acute or so intense in its nature. 

The presence of pulp stones will not usually be suspected until 
they are discovered through pulp exposure. Not infrequently they 
will seriously embarrass the dentisl in his efforts at pulp devitali- 
zation and extirpation. Sometimes in their presence it is with the 
utmost difficulty that even arsenous acid can be made to produce 
its characti ristic effect. Why this should he the case to such a 



174 ORAL PATHOLOGY AXD PRACTICE. 

marked degree it is impossible to say, as the secondary formation 
does not usually make an entire septum in the pulp chamber. 
That it may completely bar the proper filling of the roots of a 
tooth is more conceivable, for the growth may be so attached to the 
ordinary dentinal walls as to make its removal very difficult. It 
may form such an obstruction in a root canal as will absolutely 
forbid the passage of an instrument, and hence devitalized tissue 
cannot be removed, except through the slow and, under the cir- 
cumstances, uncertain process of sloughing; while subsequent 
successful filling of such a root is a mere matter of conjecture. 

The presence of secondary formations will only be positively^ 
known when the pulp chamber is opened, and then it is too late for 
anything but removal, when this is practicable. If they are float- 
ing in the pulp chamber this will not be a difficult matter. But it 
they are attached to the dentinal walls it may be impossible. It is 
not a safe practice to attempt to drill them out, nor in all cases 
would this materially assist in the subsequent treatment and filling 
of the root. The operative dentist will be obliged to take them 
out by enlarging the opening into the pulp chamber when this is 
practicable, or to use sufficient time thoroughly to sterilize any 
fragments of remaining pulp tissue; and then to fill as best he can, 
using some plastic material for the pulp chamber. 



CHAPTER XLVII. 
HYPERCEMENTOSIS. 



Hypercementosis is the analogue of hyperostosis, or exostosis, of 
bone. Technically it is a tumor, but always of benign growth. It 
is an hypertrophy of the cementum, and has its origin in some form 
of irritation that is just sufficient to stimulate the pericementum to 
an abnormal activity. It may be local, and affect but one tooth, or 
the irritation and stimulus may be so general as to induce an ex- 
cessive deposit of cementum in some form upon all, or nearly all, 
the teeth of either jaw. It may even be more comprehensive than 
that, and involve the osseous tissues. Instances have occurred in 
which hypercementosis and hyperostosis existed together, with not 
only enlargement of the roots of all the teeth, but of the whole 
alveolar process of the bone as well. Nodules of exostosed bone 



DISCOLORED TEETH. 175 

may sometimes be felt along the alveolar portions of the lower jaw 
especially, and these are apt to be associated with expansion of the 
roots of the teeth from hypercementosis. 

The condition is not one that presents very special 
pathognomonic symptoms. Unless it is accompanied by hy- 
perostosis, there will be no external indications of its existence. 
Nor is it provocative of much pain. Hence its diagnosis is at 
times difficult, or even impossible. There may be a feeling of 
pressure and general uneasiness in the teeth affected, but it will not 
be sufficient to furnish a diagnostic sign. There are no special 
complications, and hence the condition is not one of great patho- 
logical importance. Its chief import to the practicing dentist lies 
in its being an impediment to extraction, and when that is impera- 
tive may make it necessary to cut through the investing alveolar 
process before the tooth can be lifted out. This will only be called 
for at the cervical constricted portion above the expanded part of 
the root. There will have been a resorption of the investing bone 
sufficient to accommodate the hypertrophy itself, and the cutting 
through, or removal of a part of the constricted superficial alveolar 
process is but a simple operation, and is very much preferable to a 
long struggle to effect expansion in continued efforts to extract the 
tooth, with the liability to its accidental fracture under the forceps. 

Microscopical sections of portions of hypertrophies of thecemen- 
tum show that they have the true cemental structure, and there is 
no special line of demarcation visible between the new and the old 
formation. Pigmentation, or coloring, is not uncommon, its most 
usual form being a deep yellow or light brown tinge. The ceraen- 
tum corpuscles are often unusually large, so that the nutrition of 
the hypertrophied and original tissue is very well carried on, for 
perhaps obvious reasons. A clinical and microscopical study of 
the pericementum in these conditions has not hitherto been made. 
When this is undertaken further light upon this interesting subject 
will without doubt be afforded. 



CHAPTER XLVIII. 
DISCOLORED TEETH. 



While the remedial measures for (lie relief of discolored teeth 
belong rather to operative dentistry, and are outside the scope of 



1/6 ORAL PATHOLOGY AXD PRACTICE. 

this work, yet a little may be said concerning the cause of dis- 
coloration, which may be due either partially or entirely to patho- 
logical conditions. People sometimes present themselves to the 
dentist with the request that an objectionable color of the whole or 
parts of the teeth may be discharged, when it is plainly evident that 
it is congenital. Some people have yellow, and some dark teeth 
naturally, and no skill is sufficient to alter this without material 
injury. The leopard cannot change his spots, nor the Ethiopian 
his skin. 

But there are pigmentary deposits upon the surface, and stain- 
ing which penetrates to a little depth, that it is possible to remove. 
Dead dentin, the tubules of which have become filled with pig- 
mentary matter, may be bleached by chemical agents. Usually 
these deposits, either upon or within the substance of the teeth, 
are of a yellow or dark color, but in some instances the teeth are 
turned to a bright blue, or even an intense green. Workers in dif- 
ferent metals may have their teeth stained by minute particles. 
This is especially the case with brass, nickel, and copper workers. 
When this is superficial it may be readily removed, but when it 
has penetrated the substance of the tooth it presents greater 
obstacles. 

It is not usually the case that a tooth containing a living pulp 
is affected by anything beyond mere shallow exterior discoloration. 
There may be congenitally maculated spots, or atrophied regions 
that become pigmented, but any material changes of color 
are usually associated with a devitalization of the affected 
tissue. As the consequence of a sharp blow, and sometimes too 
protracted or severe dental operations, a tooth has been known 
to assume a bright pink appearance. This is, however, the result 
of death of the pulp. While the red blood corpuscles are much too 
large to enter the dentinal tubuli, they may become partially 
decomposed and their hemoglobin may penetrate the tubuli, giving 
the red tint. This is more apt to be the case in man than in 
woman, because the percentage of accidents is somewhat higher. 
After a few days changes analogous to those that take place when 
one has a "black eye" appear, but as there are no absorbents to 
take up the decomposed blood, it remains a black or dark color. 

The dentinal fibrillar themselves may, instead of being sloughed 
out, remain, and after desiccation or drying undergo slow retro- 
gressive changes that leave the dentin a dirty yellow or dark 



abrasions; pitted and furrowed teeth. 177 

brown color. Foreign matter may enter the tubuli, and there 
slowly become carbonized, and thus be the cause of discoloration. 
Substances used in filling may impart a stain to the devitalized 
dentin. Oxidation, or other chemical changes going on in metals 
used for posts to assist in the retention of fillings, may induce pig- 
mentation more brilliant than ornamental. Thus a piece of copper 
has been known to impart to a whole crown a beautiful green color, 
while nickel has given a color approaching turquoise blue. 

The most effective means for the discharge of the yellow or 
dark colors is by the use of chlorin gas. Oxygen is really the active 
agent, but the most convenient way to generate it is by the use of 
some preparation that will liberate chlorin gas, and this, in the 
presence of water, unites with the hydrogen and sets free 
oxygen, which accomplishes the work. Peroxid of hydrogen and 
pyrozone, both of which loosely hold in solution an extra volume 
of oxygen, are also used for the purpose. It is sometimes neces- 
sary to repeat the bleaching a number of times, for the discolora- 
tion is likely to return until all the degenerative changes have 
ceased. 

As it is difficult to force the bleaching agent very far into the 
dentinal tubuli, it is usual to cut out all the discolored tissue that it 
is possible to spare before commencing the process. The bleach- 
ing interferes with the integrity of the tissue, and weakens the 
tooth. Large contour restorations, after this process, are therefore 
likely to fail; this tact, with the liability to recurrence of the pig- 
mentation, has made crowning rather to be preferred in most cases. 



CHAPTER XLIX. 

ABRASIONS; PITTED AND FURROWED TEETH. 

The ordinary wear of teeth presents no unexplainable phe- 
nomena. The tooth-brush may easily account fur many channels 
and indentations. Hut aside from these, there appear occasionally 
farrows and concavities that are not congenital and that cannot be 
the consequence of any usual cause. Sometimes these occur as 
deep pits in the occluding surface of a molar, without a corre- 
sponding protuberance on it- antagonist. The channels may be 
between teeth, where no brush could reach them. They are even 

13 



1/8 ORAL PATHOLOGY AND PRACTICE. 

found in the teeth of wild and domestic animals, the brush as a 
necessary cause being thus eliminated. Cases have been known in 
which upper incisors, for instance, have the appearance of being 
regularly and evenly chamfered from the cervical portion to the 
point, as if done with a fiat file. One peculiarity of this condition 
is that the surface left is smooth, and in some instances apparently 
polished. 

Very frequently these abrasions are near the margin of the 
gum, and their edges may be too sharp and well defined to be 
caused by any form of attrition, in some instances presenting a 
distinct undercut. They may be confined to a single one, or may 
affect a series of teeth. Usually they are found only upon the 
buccal aspect, occasionally on the proximate, and very rarely upon 
the lingual surfaces. They do not seem to be necessarily connected 
with any special diathesis, for they are found in the teeth of people 
who show no indications of gout, rheumatism, or any of the dis- 
eases to which they have by some been attributed. Xo explana- 
tion has ever yet been presented that will account for all cases of 
abrasion. Chemical solution is not a sufficient explanation, 
because any acid sufficient to account for the abrasion of the 
surfaces of incisors must manifest itself in other ways; besides, 
abrasion at times occurs when the reaction of the oral secretions is 
not strongly acid. It has been attributed to electro-chemical cur- 
rents which produce electrolysis. The improbability — nay, more, 
the absolute impossibility — of the existence of such currents in the 
mouth seems too apparent to need demonstration. There is no 
question that electrical currents are constantly being formed by the 
incessant chemical action and the different molecular changes that 
never cease in the oral cavity, but it must also be as true that they 
are as perpetually and as instantly dissipated. There can be no 
closed circuits, nor any such thing as accumulation; and hence, 
while theoretically they may be present, practically they must as 
inevitably be powerless for either good or evil, vanishing on the 
instant of their birth. 

It seems to be true that while the acid reaction in some 
instances of abrasion may be weak, so far as observation goes it 
always exists. It is well known that organic acids in their nascent 
state are most active. While, therefore, through fermentation or 
in a degenerative state of the mucous follicles an acid may by 
combination be formed in a circumscribed locality, and there, on the 



abrasions; pitted and furrowed teeth. 179 

spot of its birth, have sufficient force to attack tooth substance, as 
soon as it becomes diluted and its affinities are partially satisfied 
it might give but a weak reaction when tested. In this fact may be 
found a partial answer to some phenomena. But acids would not 
probably be formed upon the most prominent labial surfaces of 
incisors, for instance, where they are most free from any foreign 
fermentable substance, and where they are constantly washed by 
the saliva and kept clean by the friction of the lips. 

A degenerative, acid condition of the secretions of the special- 
ized mucous glands at the gingival margins might, and probably 
does, account for much of the peculiar abrasion that exists in such 
localities, but it offers no explanation for that upon the occluding 
or incisive edges of the teeth. Vital depression, an atonic condi- 
tion that offers a decreased resistance to degenerative changes, are 
terms too vague and indefinite to be accepted as elucidations of 
such a condition as abrasion. 

We are simply reduced to the alternative of accepting explana- 
tions that do not explain, or frankly admitting that there is much 
in this condition which with our present knowledge is not com- 
prehensible. There are factors at work which we probably know 
not. That it is an external agent of some kind is proven by the 
fact that a protective filling, when well inserted, always screens 
the tissue that it covers. The wasting process may go on all 
about the filling, but it ceases beneath it. 

In the absence of definite knowledge of the etiology of 
abrasion, any positive prophylactic treatment cannot be 
laid down. Filling prevents penetration, but it does not in all 
cases debar extension. It forms the only effective operative treat- 
ment that can be pursued, for usually there is no polishing or 
cleaning to be done. If there is a distinctly acid reaction of the 
fluids of the mouth it shows that assimilation and nutrition are 
interfered with, and relief may be found in alterative remedies, and 
in change of climate, out-of-door exercise, or perhaps the use of 
tonics. Lime-water may be used as a gargle, and at night a 
spoonful of Phillips's milk of magnesia may be rinsed about upon 
the teeth and left there until morning, or until it is slowly dissolved 
off. Moderate friction of the gums with the brush, and massage 
with the ball of the finger, arc always stimulating and useful. 

Congenitally pitted and furrowed enamel is usually attributed 
to the influence of exanthematous or eruptive diseases during the 



l8o ORAL PATHOLOGY AND PRACTICE. 

formative period. What gives probability to this explanation is 
the fact that it is usually found upon those portions of different 
teeth which are in the same relative state of advancement as to 
growth. For instance, the summits of the first molars will be im- 
perfect, with the tips of the cuspids, while the incisors will present 
an abnormality in the shape of a furrow that is farther up on the 
face of their crowns. 

Another reason for the acceptance of this solution is that the 
abnormality never appears in the deciduous teeth, but is confined 
to the second dentition; and even then it is usually found upon the 
six anterior teeth and the first permanent molar, the premolars and 
the second and third molars, which erupt later, being free from it. 
The fact, too, that the enamel has an epiblastic origin would seem 
to connect it, though not necessarily so, with the various skin dis- 
orders. 

And yet this hypothesis does not offer a complete explanation 
of some of the phenomena presented. The enamel does not grow 
by additions at one point, but the whole of the enamel organ, as far 
as it is fully developed, will be building up enamel prisms at once. 
Any interruption of the function or any lack of nutrition would 
therefore be likely to present enamel that was imperfect over its 
whole surface, instead of at a few isolated pits, or in a narrow fissure 
across the face. In some instances this is the case, but it is by no 
means the rule. There may be but a minute pit, which extends 
well into the dentin. There may be a fissure that is longitudinal, 
rather than transverse; and one tooth alone may be imperfect, the 
others, which erupted simultaneously with it, being unaffected. 
The fact that the child had measles, or scarlet fever, or chicken- 
pox, during its early years, proves nothing; there are but few 
children who are exempt, and thousands suffer with no visible 
effects upon the teeth. 

That these congenital marks are the result of some imperfection 
or disturbance of the enamel organ during its functional life must 
be the case. It is probable that often this may be an eruptive dis- 
ease, but there must be other factors. It is readily conceivable 
that a restricted field of the ameloblasts might be functionless from 
structural causes, and this would account for isolated pits and 
imperfect places. Interruption of nutrition might account for 
others, and thus a number of causes may be active in bringing 
about the general result. 



replantation; transplantation; implantation. 181 

As it is impossible to make any diagnosis until the teeth are 
erupted, with the consequent destruction of the enamel organ, any 
preventive measures are out of the question. The trouble being 
structural, it is beyond* the domain of medicinal agents, and the 
only remedy lies in operative proceedings. When the teeth are 
sufficiently advanced they may, if the pits or fissures are superficial, 
be ground down smooth and polished. Deep pits may be filled, 
or even "jacket" crowns may be placed on them. It is a matter 
that must be left to the knowledge, judgment, and skill of the 
operator. 



CHAPTER L. 
REPLANTATION; TRANSPLANTATION; IMPLANTATION. 

Replantation and transplantation are the insertion of an 
extracted tooth in a natural, and implantation in an artificial 
alveolar socket. Replantation is the replacing of a tooth in the 
same place from which it was, either accidentally or purposely, 
extracted. Transplantation is the removal of a tooth from one 
mouth to another. In each case the success must depend either 
upon the reunion of sundered tissues or the growing of new. 
Transplantation was originally performed by placing the donor 
and receiver in the same room, and then extracting a diseased or 
decayed tooth from the latter and immediately substituting it by 
one extracted from the former, without any special preparation. 
But the unfortunate inoculation for a communicable disease in 
some instances of transplantation brought the operation into dis- 
favor. With the advance in pathological knowledge, more 
especially that of bacteriology, better methods for its performance 
have been devised. 

Replantation is called for in instances in which teeth 
have been forced from their investment by accident, or ex- 
tracted by mistake, or taken out in special conditions. There 
is no bone that heals so readily as does the alveolar process of the 
maxilla, and even though there are compound fractures the parts 
readily unite it nutrition ran be kept up in them. A tooth may be 
knocked out by accident, and may even remain out for a consider- 
able number of hours; and if it is simply washed off and placed 
back in the socket it may readily unite again. But if no antiseptic 



l82 ORAL PATHOLOGY AND PRACTICE. 

precautions are taken the probabilities are that an alveolar abscess 
will be the consequence. 

It is sometimes good practice to extract a tooth in the 
expectation of replacing it. A broach may have been forced 
through the foraminal opening, which it has been found impossible 
to remove. In a number of such cases that have presented them- 
selves to the author he has promptly extracted, removed the 
broach, given proper treatment, and reinserted the tooth, always, 
so far as he knows, with success. Cases of persistent and un- 
accountable pain that was located in the tooth have been so 
remedied. In instances of incurable alveolar abscess, perhaps due 
to secondarily infected pockets, or to foci of infection along the 
side of the root where there were Haversian canals penetrating to 
the pulp through the dentin, or in which the inflammation was of 
that low, indolent, subacute nature in which neither resolution nor 
active suppuration could by any usual means be brought about, 
the author has frequently extracted the tooth, and after proper 
treatment and preparation replaced it. Sometimes the mere trau- 
matism of the extraction was sufficient to induce an active, acute 
inflammatory stage, in place of the sluggish one. 

In all cases of plantation the most careful antiseptic measures 
must be employed. When the tooth is extracted, or as soon as 
possible after its violent removal by accident, it should be placed 
in a warm bichlorid of mercury solution for sterilization. It 
should be handled with a clean napkin, and in any subsequent 
manipulation should be frequently returned to the sterilizing 
solution, which may be kept warm by placing the vessel containing 
it in a larger one holding warm water. The pulp chamber should 
be drilled open, and its contents, with those of the root canals, care- 
fully removed. After sterilization and drying they should be 
thoroughly filled, any openings, foraminal or through the body of 
the root, being especially looked to. The apex must be made 
smooth, and if the tooth ends in a sharp point it is well to cut this 
off, carefully polishing the exposed extremity. If the perice- 
mentum which comes away with the tooth appears red and con- 
gested, it should be removed without any injury to the tooth itself. 

Placing the prepared tooth in the sterilizing solution, atten- 
tion should now be directed to the socket. This must be 
thoroughly washed out by syringing with an antiseptic solution, 
either of the mercuric chlorid I : 2000, or some other effective one. 



replantation; transplantation; implantation. 183 

If pus is present, a disinfectant like peroxid of hydrogen or pyro- 
zone should first be used. All these should be employed at blood 
temperature, or about ioo° F. If there is any specially septic con- 
dition the alveolar socket should be minutely examined with a 
probe, to determine the existence of secondary pockets, which 
should be thoroughly sterilized. 

If it is a case of transplantation, the tooth should now be tried 
in the socket, when if necessary the latter may be deepened or 
enlarged. Xo fear of any specially threatening consequences need 
be entertained, because the formation of new bone is probable and 
desirable. 

When everything is ready the tooth should be taken from the 
sterilizing solution, and quickly and firmly carried to place. A 
little subsequent pain is to be expected, because of the presence of 
fluids in the socket; these will be gradually absorbed into the 
tissues. Care must be taken that the tooth shall not, for a few 
days, occlude with any antagonist, and thus keep up an irritation. 
It must be held firmly immovable by some specially devised 
apparatus, or by the use of a ligature woven about the planted tooth 
and a few of the adjoining teeth. 

It is surprising how well the ligature, when skillfully adjusted, 
will hold a tooth. Xo surgeon would attempt to reduce a fracture 
and then neglect the adjustment of a splint to hold everything 
immovable. The ligature is frequently the best splint that can be 
employed for loose teeth. 

The only subsequent treatment necessary will usually be to see 
that all remains aseptic, li necessary, careful irrigation with a 
sterilizing solution should be kept up until new tissue has begun 
to form. If there is the least sign of infection, or of breaking 
down, it is usually better to remove the tooth, search for any 
irritants, more carefully sterilize, and insert it again. 

Implantation has become an accepted method of prac- 
tice with many oral surgeons. It had been successfully per- 
formed, but public attention was never railed to it until Dr. \Y. J. 
Younger repeatedly demonstrated its entire practicability. The 
operation consists in the forming of an artificial socket in the 
alveolar process, and the insertion into it of a tooth previously 
extracted. Nor is it essential, although it is advisable, that the 
implanted tooth shall have been recently extracted. Successful 
operations have been made with teeth that have been lying about 



184 ORAL PATHOLOGY AND PRACTICE. 

the office for years. A very superficial comprehension of the con- 
ditions involved will, however, convince any one that such an 
operation will give very much less promise of permanence than 
when a tooth not full of cracks and checks is selected. It does 
not need much physiological or pathological knowledge to demon- 
strate that, other things being equal, the better and fresher the 
tooth to be implanted the greater the chances for lasting success. 

The first thing, when implantation is contemplated, is the 
selection of a tooth. This should be done with an eye to tempera- 
ment, size, and form. The proportion of the length and thickness 
of the root to the depth and breadth of the alveolar process should 
be observed, so that proper adjustment may be possible. The 
directions given for the proper preparation of a tooth for replanta- 
tion are applicable to cases of implantation, and need not be 
repeated. 

The formation of the artificial socket in the alveolar process 
is done by laying back the gum and periosteum from the selected 
place, through the means of a crucial incision. Then with the 
proper instruments the socket is cut to a sufficient depth and 
enlarged as is necessary, the previously prepared tooth being 
occasionally lifted from the sterilizing solution in which it should 
be kept, and tried in to determine the direction, as well as the 
depth and size of the hole, which should not be so large as to 
permit the root to be loose. Finally, the tooth is inserted, and a 
proper splint or ligature used to hold it immovable. 

The operation is really but a simple one, as there are not likely 
to be any complications, unless in very rare cases tetanus might be 
induced. Should there be any indications of this, ten to fifteen 
drops of belladonna may be administered every four hours. There 
are no arteries to be avoided, or nerves to injure, if common 
prudence is employed. The point of greatest interest lies in the 
possibility of permanent attachment and the character of the 
changes that are involved. It does not seem possible that there can 
be any revivification of '.issues that perhaps have long been dead. 
As for the enamel, the proportion of living matter which it con- 
tains is too small to be taken into account. The dentin is in 
precisely the same state as in other devitalized teeth in which the 
root canal has been successfully filled. It is not at all in relation 
with any of the other tissues of the body, being completely 
enveloped and segregated by the overlying enamel and cementum. 



replantation; transplantation; implantation. 185 

The latter tissue, with the pericementum, are the only ones to be 
considered, and a little examination into their probable state may- 
be profitable. 

Osteoblasts may exist anywhere in the substance of the bone, 
or may be developed at any point where the artificial socket is 
made. Some of them must necessarily be encountered, and they 
will serve as the initial points for the growth of new bone. A new 
periosteum (or in this case pericementum) must be developed to 
form the nutritive organ of the new tissue. The inflammation 
developed by the trauma results in the effusion of the lymph neces- 
sary for these new growths, and thus the cavities in the bone are 
filled with granulations as the consequence of the development of 
a new pericementum, from the dipping down or primary additions 
to the oral mucous membrane. Without the growth of new perice- 
mentum it is difficult to imagine either the formation of new tissue 
or the nutrition of that already in existence. Under favoring con- 
ditions this is as readily organized as any other tissue, and it 
would appear that its formation must be the initial step in all these 
conditions. 

Thus we can readily account for the reconstruction of perice- 
mentum and bone. The cementum of the tooth structure is 
already formed. No instances of any further growths to it in 
these cases have been brought to professional notice. If any such 
do exist they must appear as hypertrophies, brought about 
through the formation of cementoblast cells and their physiological 
activity, a process that does not seem possible. Osteoblasts may 
be found, for there is living bone, but there is no vivified 
cementum. 

What, then, is the probable condition of the cementum of an 
implanted tooth that had for a long time been extracted? Such 
examinations as it has been possible to make in the very few 
implanted teeth that have fallen under observation have indicated 
resorption rather than growth. It does not appear that the 
cementum lacunae have ever been refilled with living matter, but 
thai the extent of revivification has been the penetration of the 
cementum by tin- transverse fibers of the pericementum, which 
thus holds the tooth firmly in place, for a time at least, and pre- 
serves it from retrogressive changes. Under these circumstances 
that which might naturally be expected too often takes place, and 
any unusual irritation, or perhaps some nutritional derangement, 



l86 ORAL PATHOLOGY AND PRACTICE. 

results in the formation of osteoclasts, with the resorption of the 
cementum. This is the usual process by which an implanted tooth 
is lost. * There being no formation of living matter within the 
cementum cells, but simply the penetration of the pericemental 
fibers, the tooth only remains in a state of tolerance. The usual 
period of retention, when the work is skillfully done, is sufficient, 
however, to justify the operation, when no special service is 
demanded aside from the preservation of appearances. 



CHAPTER LI. 

SYPHILIS: THE PRIMARY STAGE. 

Syphilis is a constitutional, infectious disease, which may be 
acquired by direct contact or by inheritance. When inherited it is 
exceedingly virulent in its character, and, next to tuberculosis, is 
probably responsible for more diseased conditions and morbid 
degenerations than any other disorder. But it is quite as true that 
there is none which so directly and unmistakably yields to 
properly directed medication. Indeed, it is the great stumbling- 
block to those who insist that drugs have no immediate remedial 
action, but that all cures are through vis medicatrix naturae — the 
recuperative or healing force of nature. There is no disputing the 
fact that syphilis is primarily influenced by certain remedies. 

The infectious character of the syphilitic virus is that which 
makes the study of the disease so important to dentists. Some of 
the lesions manifest themselves in the oral cavity, and it is possible 
for the discharge from them to be carried by instruments to the 
mouths of innocent persons and thus to inoculate them with a 
loathsome disorder. It is therefore important that the oral practi- 
tioner should comprehend the nature of the disease, and be able 
promptly to recognize the indications of its presence. It is from 
this standpoint, rather than that of its successful treatment, that it 
will here be considered. 

It is only when acquired by inoculation that syphilis presents 
all its characteristic phenomena. When it is congenital, i.e., 
inherited from syphilitic parents, it does not pass through all the 
incubative stages, and is without the initial lesion or sore. Our 
attention will therefore primarily be directed to acquired syphilis. 



syphilis: the primary stage. 187 

Although usually a venereal disease, it is not necessarily so. 
The virus may be communicated to any abraded surface, by any 
means. Thus the primary sore may be upon the lips of the person 
affected, and he or she may communicate it to another by kissing. 
Surgeons are sometimes infected when dressing syphilitic ulcers 
or when operating upon syphilitic patients. An instrument that 
has been used in such instances, if not yery carefully sterilized, 
may carry infection. But the usual source of contagion is through 
sexual congress. 

The primary sore which is produced by inoculation with the 
syphilitic virus is called the Chancre. It is located at the point of 
infection, and is single. It does not make its appearance imme- 
diately after infection, but there is a period which varies in length 
from ten to sixty days, during which the specific virus is insen- 
sibly working, before an unmistakable lesion is seen. This is 
called "the period of first incubation." 

The chancre, or primary sore, presents certain characteristics 
which, while not affording an infallible criterion in diagnosis as to 
its nature, yet when linked with the whole clinical history should 
prevent any egregious errors. But it should not be at once sus- 
pected that every sore in the mouth, upon the lips, or even the 
genitals, is of syphilitic origin, without confirmatory testimony. 
Many an innocent person has rested under suspicion because of the 
appearance of a papule, vesicle, or pustule upon some portion of the 
body. Dentists should be especially careful in their deductions, 
and should not precipitately pronounce a lesion "specific" until it 
is unmistakably proved such. 

It is a very delicate matter for a practitioner to whom applica- 
tion for professional services is made by a respectable person, 
in whose mouth or upon whose lips there exists a suspicious sore, 
to ask any pointed questions as to its origin. And yet it is of the 
utmost importance, not only to the dentist personally, but to his 
other patients, that he should know the truth. He cannot com- 
mence any special inquiries until he has something definite upon 
which to found them, for an innocent person is likely to consider it 
a mortal offense if he or she is suspected of infection with so loath- 
some a disorder. Fortunately, it is not usual for lesions to make 
their appearance in or about till month until the existence of the 
disease is well known to the patient, and before that time arrives 
he or she has probably been under the care of a physician. Know- 



1 88 ORAL PATHOLOGY AND PRACTICE. 

ing the exigencies of the case, they will then in most instances be 
ready to respond at once to guarded inquiries. But it should be 
comprehended that these remarks do not apply when the chancre 
originally appears about the mouth. It is only when the oral 
indications are secondary that the patient himself will comprehend 
their character and significance. 

The first prerequisite to the identification of a syphilitic sore 
will be found in the history of the case. If it appears upon the 
genitals, there must have been an exposure through an impure 
connection. It is needless to say that while the physician patiently 
listens, without expressing any dissent, to tales of water-closet 
infection, he will in his mind give them just the weight to which 
they are entitled. If the primary sore appears about the mouth 
there must have been a history of infection in some way, and that 
may be even less creditable than when the inoculation is through 
natural sexual intercourse. On the other hand, it may be by 
entirely innocent means. It may tax the ingenuity of the practi- 
tioner to discover some way in which to determine this point. 

The chancre, which is positively indicative of syphilitic poison- 
ing, presents these three distinguishing features : 

a. An incubative period preceding its appearance. 

b. Certain special characteristic appearances. 

c. Glandular enlargements and indurations. 

The period of incubation, as has already been stated, is an 
average of about twenty-one days. But it should not be under- 
stood that symptoms of infection will always manifest themselves 
after exposure. Some people seem to have almost an entire immu- 
nity to ordinary inoculation, and may escape when another would 
not. There are conditions of the system in which one is more 
liable to infection than in others, as is the case with other commu- 
nicable disorders, so that a person may possibly pass through the 
fire more than once without being burned. Very old and very 
young persons are especially liable to infection, because of their 
weak resisting powers; and the same may be said in anemia, 
malaria, alcoholism, and other atonic conditions. 

The first appearance of a chancre is usually as some form of an 
erosion. It may be quite inconspicuous, and so remain for a time 
unnoticed. When recognized, it will be observed as a roundish, 
oval, or irregular macule, or spot, resting upon a slightly indurated 
bed. and feeling to the touch like a piece of parchment or cartilage 



syphilis: the secondary STAGE. ISO. 

let into the tissue beneath. In size this varies from a pin's head to 
that of a dime, or even larger. Its color is a dull red, which has 
been aptly characterized as that of "raw ham," and this hue seems 
almost pathognomonic. It may be level with the neighboring- 
skin, or its edges may be slightly raised and its center depressed. 
It may be dry and glazed, or slightly moist, secreting a thin serum, 
which in drying glues to the surface any dressings, clothing, etc. 
This serum is very infective. 

The chancre rarely suppurates or degenerates into an ulcera- 
tive stage, save when macerated, as by the fluids of the mouth. 
After ten days or so it is apt to break down and make an abraded. 
sore, but it is not painful, nor are there any special functional dis- 
turbances attending it. ;But any superficial irritation may develop 
an ulcerative condition, either shallow and superficial or deep and 
crater-like. In all cases the distinctive indurated base, which is 
characteristic of the primary syphilitic sore, will be observed, and 
it is upon this sclerosis that one will largely rely for his diagnosis. 

The chancre may persist until the appearance of the indications 
of systemic syphilis, but it usually disappears without leaving any 
scar or other local indication of its presence. It is in this primary 
stage that mercury is peculiarly useful. Under its influence the 
chancre usually heals readily, and the progress of the systemic 
infection is slightly checked. It is usually given in as large doses 
as is possible without producing too profound mercurialization. 



CHAPTER LII. 
SYPHILIS (Continued): THE SECONDARY STAGE. 

WlTH the disappearance of the primary sore the uninformed 
person might imagine the disease cured, but this is by no means 
the cage. The virus is active in the system, though without any 
outward manifestation, until the period of secondary incubation 
has passed, when the indications and symptoms show thai it is no 
longer local in its nature. 

Closely connected with the appearance and progress of the 
chancre there is an affection of the glands in the immediate neigh- 
borhood. This consists in an enlargement and induration, or 
thickening and hardening of neighboring lymph centers, withoul 



190 ORAL PATHOLOGY AND PRACTICE. 

special soreness or other change in them. It may be considerable, 
or it may be so slight as scarcely to be noticed. It is not a 
manifestation upon which the practitioner can confidently rely in 
making a diagnosis of primary syphilis, but it may in some in- 
stances materially assist. It is to be classed with other inconstant 
symptoms and indications, all of which are to be grouped together, 
and the absence of any one of which neither proves nor disproves 
anything. It should be understood that in case of the appearance 
of this indication it will only affect the lymph nodes that are in 
nearest anatomical relation with the primary sore. If this is upon 
the genitals the chain of glands in the groin will be the limit of 
affection, while if it is about the mouth the probable boundary will 
be the cervical glands. 

The second period of incubation is that between the appearance 
of the initial sore and the manifestations of constitutional disturb- 
ance. These consist of the so-called syphilides, or eruptions upon 
different portions of the body. As has been already stated, the 
chancre is local in its character. The secondary eruptions indicate 
that the virus has permeated the whole body. The first period of 
incubation is that in which the diseased condition is obtaining its 
limited hold. During the second it is disseminating its baneful 
influence and fastening its grasp upon all the tissues of the 
organism. Its general progress may be marked by the glandular 
involvement, for it is through the lymph system that the degenera- 
tive influence spreads. 

The second period of incubation varies from twenty to one 
hundred and fifty days, fifty being about the average. As the 
chancre is the characteristic indicative of the primary, so these 
syphilides are the most constant manifestations of the secondary 
stage. They consist of eruptions of various character, which 
appear upon different parts of the body. The first is usually a 
kind of roseola, or blush, or redness of the skin, not unlike that of 
scarlet fever. It commonly covers the thorax, occasionally the 
abdomen, and sometimes the whole body, but seldom includes the 
face. It is symmetrical, appearing about equally upon both sides 
of the body. The first eruptions are almost always superficial, 
and are accompanied with no pain or itching, and spontaneously 
disappear after a variable period. 

After the first or superficial eruptions shall have run* their 
course, they are succeeded by, or degenerate into, those of a papular 



syphilis: the secondary stage. 191 

or pimple form. These show a deeper affection of the skin, but 
they may begin with the roseolar or superficial variety. Xot in- 
frequently the papules may be seen invading the erythema, or blush 
eruption, and becoming more and more pronounced. The color of 
the eruption may change from the pinkish hue to a brown or 
yellowish red. The pimples or papules vary in size from that of a 
pin's head to a pea. They are sharply defined, circumscribed, 
and project above the level of the skin. Sometimes they break 
down and suppurate, but more frequently they heal without a 
scar. During this process of healing they frequently exfoliate in 
the form of scales, forming the squamous syphilide, which may be 
readily mistaken for psoriasis, or itch. 

Another form which the syphilodermata, or syphilides, assume 
is that of the pustule. Pustules occur most frequently on the lower 
extremities and the scalp, as cone-like elevations, which give rise 
to large, irregularly shaped ulcers, secreting a bloody pus that 
dries up and forms dark brown or black crusts. The ulceration 
goes on beneath these crusts and about their edges, the secretion 
overflowing and forming a superimposed and larger crust, and 
thus in time a kind of corn is produced, consisting of successive 
layers. These appearances are not usually observed until at least 
six months have elapsed. 

During all this time the enlargement and induration of the 
glands has been increasing and extending. At this period they 
may probably be plainly felt along the posterior border of the 
sterno-cleido-mastoid muscle, the other cervical glandular regions, 
and those of the supraclavicular and epitrochlear localities. They 
vary in size from that of a pea to a pigeon's egg, are round, hard, 
and painless. 

At the same time the constitutional disturbance begins to 
manifest itself in fever, the temperature rising perhaps to 102 F., 
in pains of neuralgic or rheumatic character, and in severe head- 
aches, with sleeplessness and restlessness. All of these arc worse 
at night. 

It should always be borne in mind that the characteristic secre- 
tions of the syphilodermata are infectious in the highest degree. 



192 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LIII. 
TERTIARY AND HEREDITARY SYPHILIS. 

Tertiary Syphilis is the final result of the specific infection. 

It is a breaking down of the tissues under the degenerative process, 
and is characterized by a worse series of syphilides, by necrosis of 
the hard, and ulceration, sloughing, and perhaps gangrene of the 
soft tissues. It is a process of general destruction, and some of its 
forms are repulsive in the extreme. The discharges are not, 
however, of such an infectious nature, and hence it is of less interest 
to dentists than the earlier forms of syphilis, but it should not be 
imagined that they are wholly without danger. 

The syphilides in the tertiary stage take the usual form of 
gummata and condylomata. The former commence with circum- 
scribed, firm nodules beneath the skin or mucous membrane, vary- 
ing in size from a small cherry to that of an orange, or even 
larger. At first the skin is uncolored, but later it changes to livid, 
or purple, becomes thin at the apex, and finally ulcerates. They 
are not ordinarily numerous, seldom exceeding three or four in one 
subject. They usually leave a deep and abiding scar. 

The condylomata, or venereal warts, are morbid growths, the 
result of syphilitic infection in its later stages; but, as their observa- 
tion will seldom come within the province of the dentist, they need 
not be considered here. There are also tubercular deposits and 
complications, whose chief interest in this connection is that their 
presence may sometimes prohibit surgical operations. 

The chancroid, or soft chancre, is a sore which does not carry 
in its train any of the constitutional complications of the true Hun- 
terian chancre. It is of a pustular nature, with a secretion that is 
peculiarly infectious, but which, unlike that of the true chancre, is 
auto-inoculable; that is, it infects the person in whom it exists at 
any new point with which it comes in contact, making another 
chancroidal sore. Hence chancroids are usually multiple, while 
the chancre is single. Chancroids very rarely appear elsewhere 
than upon the genitals, and produce no oral lesions whatever. 

Hereditary Syphilis. 
The infection of hereditary syphilis may be transmitted 
through either parent, or by both. In the father the spermatozoa 



TERTIARY AND HEREDITARY SYPHILIS. 



193 



are affected, while in the mother it is the ovuin. If a mother 
acquires syphilis after her impregnation, she may transmit the 
disease to the fetus through the placental circulation. A healthy 
mother who gives birth to a child inheriting syphilis from the 
father may herself be infected, although the disease will be likely 
to assume a modified form. When there is impregnation, either of 
the parents being afflicted with recent syphilis, it is usually fatal to 
the fetus, either before or shortly after birth. The longer the time 
between the infection and the impregnation, the less will be the 
chance of transmittance, or the milder the form that the disease 
will take, especially when the parents have been under treatment. 

The prognosis in inherited syphilis is much more grave than in 
the acquired form. From one-third to one-half of all syphilitic 
children die before reaching adult life. 

The first symptoms of inherited syphilis, the early syphilides, 
usually appear within the first three months. If an infant arrives 
at the age of six months without exhibiting any of the indications 
of syphilis, it may be safely assumed that it is healthy. 

Syphilitic children are poorly nourished and anemic, and do not 
develop normally, either physically or mentally. They possess little 
ability to resist disease, and too often fall early victims to different 
disorders. 

1 [utchinson first called attention to a peculiar formation of the 
tissues of the teeth that he believed to be indicative of hereditary 
syphilis. This,' he declares, is confined to the permanent superior 
central incisors. When erupted these teeth are thin, narrower at 
the point than at the base of the crown, with a crcscentic depression 
of the central part of the cutting edge; that is, they are longer at 
their mesial and distal cutting angles than in the center". Hutchin- 
son declared that when deafness, interstitial keratitis, and notched 
teeth are present in the same person, hereditary syphilis is positive. 
It is not probable that either alone is pathognomonic, and the 
notched teeth certainly are not an infallible indication, as they may 
be the resull of other causes. 



194 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LIV. 
SYPHILIS OF THE MOUTH AND TONGUE. 

It was necessary to investigate the pathological changes that 
take place in syphilitic affections before its manifestations could 
be comprehended, or recognized when seen. If the nature of the 
syphilides is not learned, the student will not be prepared to under- 
stand their import when he meets them in practice. But it will be 
the oral phenomena that will chiefly concern him, and hence these 
should be awarded special attention, because of the possibilities of 
the transmission of the disease through his instrumentality. 

The practitioner has already been cautioned against jumping 
to the conclusion that every mucous patch in the mouth, or every 
indurated sore, has a specific origin. Any excoriation of the 
mucous surface may be greatly aggravated by special irritants that 
are common in the mouth. The chewing and smoking of tobacco, 
the holding of pipes, cigars, and cigar-holders, the drinking of 
hot and iced fluids, may intensify a local irritation until it assumes 
a very suspicious aspect. In the game manner syphilitic sores of 
the mouth may take upon themselves an irritated character or 
appearance. But it should be borne in mind that these aggrava- 
tions do not in essence differ from the same morbific changes 
occurring in other parts of the body. 

Chancres occurring upon the tongue, the lips, or the tonsils, 
although somewhat modified by their surroundings, present the 
same distinguishing characteristics as when they appear elsewhere. 
The same may be said of the maculae or roseola, the papules, pus- 
tules, and ulcers which have already been considered. Rough or 
carious teeth may aggravate them, and modify their appearance, 
but they will not destroy their leading characteristics. As a rule, 
the syphilitic lesions of the mouth are of a moist rather than a dry 
nature, and mucous patches are of greater frequency. 

In the early stages of secondary syphilis, the eruption may 
appear in the mouth as well-defined areas of a dark red color, upon 
the soft palate, tongue, pillars of the fauces, and along the gingival 
labial borders. These may be of any size, from mere points to 
blotches covering the whole surface. But they will retain the sym- 
metrical appearance of the cutaneous eruptions, and will usually be 
seen upon both sides of the median line. Like those of the surface, 



SYPHILIS OF THE MOUTH AND TONGUE. 195 

they may disappear after proper treatment, or they may form the 
basis for further degenerations. They usually become eroded to a 
greater or less extent, this probably being due to local irritation. 

The papular syphilide of the cutaneous surface is represented 
in the mouth by mucous patches or moist papules. These may be 
single or multiple, and they are usually well defined, varying in size 
from a single point to that of a quarter dollar. They are at 
first red in color, but soon assume a whitish appearance, looking 
as if the mucous membrane had been cauterized with nitrate of 
silver. They are often raised above the general level, and are 
more or less painful. Two of them may perhaps be seen facing 
each other on membranes that are in contact, like the surfaces just 
back of the last molar tooth, or those of the cheek and the alveolar 
wall. Upon the dorsum of the tongue the papules may become 
confluent, giving the characteristic "toad's back" appearance. Not 
infrequently the tongue is swollen, and presses against the teeth 
until its edges appear serrated, or scalloped. 

The ulcerative lesions are usually the further breaking' down 
of the mucous patches, and their deep erosion until they form con- 
siderable caverns in the tissue, which are exquisitely painful. 
Thes? may follow along the lines of the tongue, thus giving rise to 
deep fissures, or they may burrow into the crypts of the tonsils, or 
form circular pits on the posterior wall of the pharynx. Not only 
are fissures formed in the tongue, but they make their appearance 
at the corners of the mouth or the centers of the lips. 

An acute glossitis or inflammation of the tongue is not infre- 
quently the result of syphilitic infection. There may be first an 
hypertrophy of the organ, with subsequent contraction, thus caus- 
ing deej) transverse or longitudinal furrows. There may be an 
indurative or hardening change in the muscular fibers, with a 
consequent partial loss of function, the speech becoming thickened 
and indistinct. Along the borders of the tongue dry or squamous 
lesions sometimes may be seen. They are not moistened by the 
usual secretions of the mouth, and in color are of a grayish or 
bluish white, sometimes having a glistening appearance. These 
patches arc specially marked among users of tobacco, particularly 
those who aie smokers, and there is a distinct variety that has been 
called "smoker's patches." They are not by any means confined 
to the borders of the tongue, or even to the tongue itself, but they 
may appear anywhere in the oral cavity. 



I96 ORAL PATHOLOGY AND PRACTICE. 

Gummata of the mouth may develop during the later stages of 
syphilis. Their initial appearance is as nodules beneath the mucous 
membrane, from the size of a pin's head to that of the end of the 
thumb, usually single, but sometimes multiple. After a time they 
break down into ragged ulcers, and their degeneration is usually 
rapid. Perhaps one appears in or near the center of the vault, and 
when it breaks down a probe will detect necrosed bone, which is 
soon exfoliated, thus causing a perforation of the hard palate. 

The syphilides of the mouth assume a variety of forms, 
and sometimes their diagnosis is impossible, except with the 
aid of the history of the syphilitic infection. They may pos- 
sibly be mistaken for other affections. The roseola may be con- 
founded with a follicular stomatitis, and the ulcers with cancrum 
oris, or noma. Epitheliomata may be almost indistinguishable 
from some of the syphilitic lesions, though ordinarily they are much 
slower in their progress. Mercurialization may usually be distin- 
guished from syphilitic disturbances by the fetor of the breath, and 
by the distinct metallic taste. But there may be innocent ulcera- 
tions upon the tongue or oral tissues, which the experienced 
syphilologist might mistake if he were to depend upon their 
appearance alone. The only safe course is to group the various 
symptoms, examine for glandular indurations, and carefully and 
delicately inquire into the history of the case when suspicious 
appearances are observed in the mouth, all the time observing 
caution to guard against possible infection, for if there happens to 
be, as is frequently the case, any abraded or wounded point in the 
fingers, it is possible for syphilitic inoculation to take place from a 
secreting mouth-plaque. It is perhaps unnecessary to say that 
some form of iodin is the specific remedy for constitutional syphilis, 
more especially potassium iodid, exhibited if necessary in heroic 
doses and continued for an indefinite time. 



CHAPTER LV. 
PHYSICAL DIAGNOSIS. 



The oral physician should be competent to make a proper 
examination of a patient, for the purpose of ascertaining the ability 
to withstand an operation, to take an anesthetic, or to determine 



PHYSICAL DIAGNOSIS. IGJ 

the probability of constitutional complications. When the regu- 
lar physician approaches the bedside of a sick person for the 
purpose of making" a diagnosis he first takes the pulse, that he may 
determine the condition of the circulation. He next looks at the 
oral tissues, especially the tongue, because upon it he will find 
reflected any disturbance of the digestive tract. When he has 
learned to read these aright he has the key to the state of the two 
most important functions of the body upon which, more than any 
others, health depends. 

To be able to interpret correctly the utterances of the pulse, 
of the breathing, or of the oral tissues, it is essential that the physi- 
cian know the language in which they speak. The technically un- 
instructed man may feel the pulse, but to him it tells nothing 
except that the heart is beating more or less regularly. The 
accomplished physical diagnostician with his eyes shut will at 
once pronounce whether the patient is strong or weak ; is nervously 
excited or depressed; is in a fever or rigor; whether the disturb- 
ance is functional or organic; whether in the brain or extremities; 
whether there is or is not narcotic or other poisoning, with many 
other matters that it is essential to know. 

The principal methods for determining the state of the internal 
viscera in physical diagnosis are auscultation and percussion. 

Auscultation is the determination of the condition by listening to 
the sounds which are produced in normal or diseased functions. It is 
called immediate when the ear is applied directly to the part, and 
mediate when a stethoscope or other instrument for conducting the 
sound is employed. 

Percussion is the striking lightly upon any part of the body, 
especially tin- thorax or abdomen, with the view of determining diseased 
conditions by the resonance or lack ol resonance ol the sound. It is 
called immediate when made direct with the fingers, and mediate 
when a pleximeter or some instrument is used to increase the 
sound. Usually immediate percussion is employed by laying the 
firsl two fingers of the left hand upon the part, and striking them 
with tlu- ends of the first two fingers of the right hand. 

Perhaps the dentisl may not need t<> become an expert, hut 
he should at least know tin- most important expressions of the 
heart, the lungs, and the digestive trail, as expressed iii the pulse, 
the breathing:, and the oral tissues. 



i98 oral pathology and practice. 

The Pulse. 

To be able to recognize the pulse in disease, it is necessary to 
know what it is in health. It varies in different individuals, and 
changes with their condition. It is not the same during growth as 
in maturity, and every physical state has its appropriate expres- 
sion. There is a difference of five to six beats per minute between 
the pulses of men and women of relatively the same general physi- 
cal condition otherwise. A difference of from five to ten beats is 
made by change of posture from lying down to sitting, and from 
sitting to standing. By violent running, or any excessive exercise, 
the rate may be doubled. It is higher in infant than in adult life, 
and it decreases yet more in old age. 

The pulse may be felt at any accessible artery, the larger 
and nearer the heart the more distinctly. It is usually exam- 
ined at the point of nearest exposure of the radial artery, in the 
wrist, but dentists should be able to read the pulsation of the facial 
artery, where it crosses the inferior maxilla, because it is more 
convenient, especially in the administration of anesthetics. It may 
also be taken from the carotid artery in the neck, or the temporal 
beneath the ear. 

If the pulse is taken at the radial artery the tips of the 
first two fingers should be used, with the second finger 
nearest the heart. The strength is determined by pressing with 
the second finger until the pulse cannot be felt with the first, and 
taking note of the amount of force required to compress the artery. 
The number of pulsations are computed by counting. The pulse 
should never be taken when the patient is in any state of excite- 
ment, because its true reading cannot be obtained at that time. 
When first placed in the chair, or if a view of the instruments is 
obtained, the pulse may be raised several beats, and will be changed 
in its character. The best time will be after the patient has entered 
the office and sat for a few moments, until all nervous excitement 
shall have passed away. Then, in the midst of conversation and 
without intermitting it, the hand may be taken and the pulse 
examined. Of course, no alarming display of instruments or 
apparatus will be permitted. 

At birth the pulsations are from a hundred and twenty to one 
hundred and forty per minute. The rate gradually diminishes until 
at seven or eight years it is about ninety. In adult life it is from 
sixty-five to seventy-five, while in old age it sinks to sixty. Some 



PHYSICAL DIAGNOSIS. 199 

people have normally a very slow pulse, while others have one 
that is rapid; hence it is essential to have some knowledge of 
what is the normal rate. But an experienced physician will tell by 
its reading whether the slow or fast pulse is the result of some dis- 
turbing influence, or whether it is normal. 

In disease the pulse presents certain modifications that depend 
upon the kind of disturbance. In the principal changes certain 
definitions are given which are definite in their meaning. For 
instance, there is a marked difference between a rapid, a quick, and 
a frequent pulse, and each conveys its own tale. The principal 
modifications are as follows: 

A frequent pulse means one that is diminished in force, but 
increased in frequency. It is the result of and indicates debility. 
Thus before death it may be so frequent as almost to be beyond 
counting, and so weak as to be almost indistinguishable. The 
muscle of the heart is losing its contractile force. 

A quick pulse is abrupt, jerking, and may be -moderate or frequent 
in its rate of pulsation. It indicates some irritable state of the heart, 
which may be only of a temporary nature. 

The slow pulse (unnaturally so) occurs in narcotic poisoning and 
in apoplexy. Jt will be found in compressions of the brain from 
accident, and in unconsciousness from opium or liquor. This 
characteristic enables the physician to determine malingering, and 
the simulation of unconsciousness. Another method to detect 
counterfeiting is to press the ball of the thumb with considerable 
force on the supra-orbital foramen for one or two minutes, gradu- 
ally increasing it. No conscious person can long withstand this. 

The hard pulse seems to indent the linger, and is what the name 
indicates. It shows great excitement of the circulation, with high 
tension and rigidity. 

The soft pulse is the direct opposite of this, and indicates lassitude. 
It i- easily compressed, though it may not be readily extinguished. 

The febrile pulse is an increase in the rale of pulsation, and 
Usually of force also. It is found in active fevers and inflamma- 
tions of an acute character. 

The feeble pulse is nearly synonymous with the soft pulse, but is 

move easily extinguished. It is indicative of greal debility and 
exhaustion. 

The thready pulse is one that gives beneath the linger the sensation 
of a vibrating thread. It is allied to the wiry pulse, which is an 



200 ORAL PATHOLOGY AND PRACTICE. 

exaggerated condition. Both are sometimes present in very great 
debility. 

The irritable pulse is one that is both frequent and hard. It will 
be found when a debilitated person is subjected to some kind of 
excitement. 

The intermittent pulse is one that now and then loses a beat. It is 
indicative of either functional or organic disease of the heart. It 
should not be confounded with the weakened pulsations of exhaus- 
tion. 

The irregular pulse is one that varies in both frequency and force. 
It may be very slight, or it may be extreme. It is generally found 
in heart disease, but it may be the result of the use of tobacco or 
strong coffee or tea. The inordinate use of stimulants may also 
produce an irregular pulse. 

The practitioner should lose no good opportunity for the study 
of the pulse, both in health and disease. He will find that his 
comprehension of it and his ability to detect variations will greatly 
increase with practice. He must learn to read it as he would 
Greek, by first conquering its alphabet, and then slowly and 
patiently acquiring the combinations. He will discover that he 
can acquire real skill and facility in reading the one about as easily 
as the other. 

It should be comprehended that all these modifications are not 
produced simply through changes in the force exerted by the heart 
in its pulsations. The readings depend upon the condition of the 
coats of the arteries quite as much. Their resilience, or elasticity, 
is governed by the vaso-motor nerves, and hence any nervous 
shock or neural depression will be readily manifested in the arterial 
walls, in the manner indicated in the section on Inflammation. 
Thus the "hard" pulse and the "soft" pulse will mainly depend 
upon the tension of the muscular arterial coats, while the "slow" 
pulse and the "frequent" pulse will be the result of the condition of 
the heart, or the rate of its pulsations. 

A "feeble" pulse indicates that the force of the heart-beats is 
lessened, and at the same time the tension and resiliency of the 
arteries themselves are reduced. The "soft" pulse, on the con- 
trary, simply implies a change in the coats of the vessels, without 
any special heart complications. 

The "hard," or "wiry," or "thready" pulse shows an undue 
tension of the arterial coats, and this will be induced through some 
nervous impression acting through the vaso-motor system. 



PHYSICAL DIAGNOSIS. 201 

It may thus be seen that the pulse gives a very clear indication 
of the state of the nervous system, and reveals any neural shock or 
depression; and that at the same time it is indicative of the state of 
the blood column and of the functional activity or languor of the 
heart. 



CHAPTER LVI. 

PHYSICAL DIAGNOSIS (Continued). 

The Respiration. 

The various sounds made in breathing, as well as those of the 
heart, may be determined by the use of the stethoscope, or by 
placing the ear to the chest, not more than one thickness of cloth 
intervening. 

The breathing is termed either abdominal or thoracic. That 
is, the muscles chiefly used may be the diaphragm or the costal and 
superior thoracic. The breathing in man is mainly abdominal, 
while in woman it is thoracic. In forced and labored respiration 
yet other muscles may be brought into action, as the trapezius, 
serratus magnus, and the sterno-cleido-mastoid. 

In health, the respiration is from thirteen to twenty-five per 
minute. In the dyspnea of pneumonia it may rise to from thirty to 
fifty per minute. 

The normal respiration should be without effort, deep, and 
unhurried. There should be no unusual noises or rales, and the 
natural murmurs of the passage of air through the bronchial tubes 
should be present when the ear is placed to the chest. 

The amount of air respired by each individual is about five 
hundred cubic centimeters, and, of course, the same amount is 
exhaled. But it should not be understood that all the air is 
expired at any one time. After the fullest expiration there will 
still be left in the lungs fifteen to eighteen hundred cubic centi- 
meters. In forced expiration, or exhaustion, most of this air may 
be forced out. 

The purification of the bl 1 is through the process of respira- 
tion. ( Ixygen is taken in. and carbon dioxid, water, and various 
organic matter are exhaled. A greal deal of effete matter is 

eliminated from the pulmonary surfaces. In the administration of 

anesthetics they are usually taken into the lungs by inhaling the 



202 ORAL PATHOLOGY AND PRACTICE. 

vapor, and thence pass directly into the blood; in their elimina- 
tion it is chiefly the lungs which throw them off. They circulate 
with the blood until they again reach the pulmonary surfaces, when 
they are given up. Hence, in the recovery from the anesthetic 
state, it is of the first importance that the breathing be maintained 
evenly and regularly, as otherwise the poison remains in the 
system. 

In diseased conditions the respiration may be either faster or 
slower than the normal. When it is very much accelerated it will 
probably be superficial, shallow, and gasping. This will be the 
case when it is above thirty-five, in pneumonia, pleurisy, obstruc- 
tions in the trachea, or any kind of dyspnea. 

It will be retarded and will be deep in narcotic poisoning and 
in cerebral compressions, falling as low as twelve to the minute. 

When the lung is filling up, becoming consolidated, it will be 
interrupted, broken, and irregular. 

Bronchial breathing will be marked by blowing, as through a 
tube, and it will have a high pitch. This will be the case in 
advanced phthisis, in exudations, hemorrhages of the lungs, etc. 

The sounds that are heard as the air rushes through the various 
passages may be moist or dry; may have their location in the larynx, 
the trachea, the bronchi, the air vesicles, or in cavities that may 
have been formed by disease. 

The bubbling sound may be coarse or fine. The coarser it 
is the higher up it will be, and the weaker will be the patient. It 
means the presence of water or moisture in the passages. 

Gurgling, like water boiling, may be heard in pulmonary cavities 
at times, and indicates an advanced state of phthisis. 

Splashing sounds upon succussion, or shaking or striking the 
chest, in the pleural organ indicate hydro- or pyo-pnenmothorax — water 
or pus, with air, in the pleural cavity. 

Loud zuhistling or wheezing that may be heard at a distance in 
the larynx or trachea indicates stenosis, or constriction, and is heard 
in croup. 

Low-pitched snoring in the larger bronchi means spasms, or nar- 
rowing of the bronchi, as in asthma. 

A crackling sound located in the air vessels of the lungs shows a 
sticking of their walls, and is heard in pneumonia. 

Creaking, grazing sounds arc heard in pleurisy, and indicate 
exudations upon the surfaces of the pleura. 



PHYSICAL DIAGNOSIS. 2C>3 

Metallic, tinkling sounds in pleural or pulmonary cavities mean 
pneumothorax, or the escape of air into some cavity. 

The rales (French "raler," to rattle) are the sounds caused by 
the passage of air through impediments in the lungs or bronchi. 
They are divided into the dry and the moist. 

Dry rales will usually be induced by a condition of the air passages 
in which they arc not lubricated with the normal mucous secretion, or 
when it is inspissated or thickened; hence they arc usually of a crack- 
ling or whistling character. 

Moist rales arc produced when the obstruction is fluid, and are 
apt to be of a bubbling nature. Peculiar conditions may, however, 
modify either of these, and special pulmonary diseases have their own 
specific rales. 

Cavernous rales arc observed when there is a cavity filled with 
pus. 

Crepitant rales arc the crackling sounds symptomatic of the first 
stage of pneumonia. 

Mucous rales are the bubbling sounds produced by the passage 
of air through bronchial mucus. 

Sibilant rides are those that have a sharp, hissing sound, as when 
air passes through a contracted moist passage, or through foaming 
fluids. 

Sonorous rales arc the stertorous, snoring sounds, as if the air 
were interrupted by some rib rating substance. 

Friction rales are the creaking sounds heard "when, without the 
lubricating fluid that is natural to them, two surfaces rub upon each 
other. 

1 'esieular rules are the tine crepitant sounds heard in the vesicles 
of the lungs in tin 1 early stages of inflammation. 

Suhcrcpilanl, or tracheal, rales are heard when mucus accumu- 
lates in the larger bronchi, or the trachea, and they farm what is coiled 
the "death rattle," usually a premonitory symptom of dissolution. 

Other sounds heard in auscultation are called murmurs, and 
they are caused by the friction of moving currents of air or fluid. 
Sometimes the French term bruit, having the same signification, 
is empl< >yed. 

The arterial murmur is the sound made by the arterial current, 
and it may be normal or disturbed. 

The cardiac murmur is the union of the systolic (contracting) 
and diastolic (dilating) sounds produced by the muscular odious of 



204 ORAL PATHOLOGY AND PRACTICE. 

the heart and the passage of the blood through its auricles, ventricles, 
and valves. 

Hemic murmurs are the sounds due to changes in the quality and 
amount of the blood itself, and not to modifications in the vessels or 
valves. 

Respiratory murmurs are the sounds produced by the passage of 
air through the lungs and bronchi in inspiration and expiration. 

The venous murmurs arc the so-called "bruit de diable" of the 
French, produced in the common jugular in anemia, lead-poisoning, etc. 

Artificial Respiration. 

The dentist will not infrequently be called upon to use artificial 
respiration, and a few plain, uncomplicated directions are necessary. 
Many persons each year are lost whose lives might readily enough 
be saved if this subject was better understood. Xo one should be 
pronounced dead as long as there is the very slightest flutter of the 
heart, or when there is any vital warmth present. People have 
been restored after hours of unremitting efforts, unrewarded by 
even a gasp until near the end. Artificial respiration has held 
death at bay for days before any voluntary efforts could be induced. 

In cases of cessation of breathing- not an instant should be lost 
in getting the patient into a prone or recumbent position, if he is 
not already so placed. All clothing should be loosened and the 
tongue seized with a pair of forceps, or a tenaculum, and forcibly 
drawn forward, at the same time raising the head a little to insure 
the opening of the glottis. Something should then be placed 
under the patient's shoulders to raise the chest. The coat of the 
operator is excellent, if nothing else is at hand. 

The most simple and easily comprehensible method of pro- 
ducing artificial respiration is that called "Sylvester's," and either 
this or some other that is equally effective should be at once 
employed. The operator will place himself at the head of the 
unconscious person and seize the wrists. Then by a sweeping 
motion the arms should be extended, and at the same time hori- 
zontally carried to their fullest extent above the head. After an 
instant's interval they should be carried back by reversing the 
motion until they rest across the body just below the diaphragm, 
when firm pressure upward and against the body should be exerted. 
These motions should be continued about fifteen times per minute 
for an indefinite time, at the same time keeping up the bodily heat 
by the use of hot-water bottles, hot flannels, and chafing of the 
extremities. 



THE ORAL TISSUES IN DIAGNOSIS. 205 

When there is sinking after the giving of an anesthetic, or in 
cocain or opium poisoning, artificial respiration may be necessary; 
but if breathing is once established the patient should be exercised 
as violently as practicable to assist the circulation and to aid in 
the elimination of the drug. A hypodermic injection of branch- 
may be administered, or one of ammonia. Strong coffee is an 
excellent antidote, as is any stimulant. Cocain poisoning will be 
manifested by symptoms very like those due to opium. People do 
not die of cocain poisoning except after the lapse of some hours, 
and the narcotic effects are plainly visible for some time before 
death ensues. The instances in which it is related that death 
occurred within a few moments after the injection of a cocain 
solution were doubtless errors of diagnosis. The patient probably 
died of something else than narcotic poisoning. 



CHAPTER LVII. 
THE ORAL TISSUES IN DIAGNOSIS. 

All gastric disturbances are reflected in the tissues of the 
mouth. The tongue especially is very expressive, and the oral 
physician or dentist should learn to read its indications as he would 
an open book. 

In health, the tongue is of a delicate whitish pink color, 
smooth and moist. Any departure from this appearance, 
either in the tongue or the other oral tissues, means a 
pathological state that demands the attention of a doctor. 
In another chapter, local inflammations with their symptoms have 
been described, and it remains but to give the appearance in 
general functional disturbances. 

The tongue is at times covered with a coating called 
" fur." This always indicates defective circulation of some 
kind. Fur consists of the unremoved epithelia of the mucous 
membrane, of the thickened, inspissated mucus, of the debris of 
food, or of some deposit. In pathological conditions the furring 
of the tongue is by regular gradations, commencing at the base 
and spreading toward the tip. In clearing Up this is reversed, the 
clean spots first appearing at the end and sides, and spreading 
toward the base, s<> that by watching the progression or rctrogres- 



206 ORAL PATHOLOGY AND PRACTICE. 

sion of this process a fair knowledge of the progress of the disease 
may be obtained. 

Generally speaking, a dull whitish color of the tongue indicates 
a hyperacid condition ; while red, with fur, points to an alkaline or 
inflammatory state. 

A delicate whitish tint of the tongue within two hours after eating 
means that digestion is not completed. This tint should not be con- 
founded with disease indications. If the tint remains for more 
than four hours it means arrested digestion. 

White, with a thin coating, means acidity. A yellowish white, 
acidity with biliary irritation. A very white and thick coating 
("flannel mouth" ) means intense venous congestion, as in cerebrospinal 
meningitis. 

Red, a delicate pinkish tinge, indicates that digestion is completed. 

Red of a deeper hue means arterial congestion. 

Red, a very deep and dark tinge, means the last condition very 
much exaggerated. 

Red, bright in color and raw or glased, indicates paralysis of the 
sympathetic — approaching fatal exhaustion. 

Brown, or brownish red, with a thick dry coating, means prostra- 
tion; arterial congestion; carbonic acid poisoning — a sign of danger. 

Black, or blackish, not deep, means blood poisoning — pyemia; 
sepsis. 

Blue, or a bluish tinge, indicates lack of oxygen; cyanosis. 

Humidity of the tongue means atony (lack of tone), with anemia. 

Dryness means nervous irritation; debility. 

Flabbiness, fullness, treiuulousness, indicate great debility. 

Imperfect muscular movements, difficult articulation, means 
cerebrospinal irritation; drunkenness. 

The tongue may be furred in health, as in excessive smoking. 

A dry tongue may be due to fever or to loss of sleep, or to 
some deep nervous impression. 

In old age the tongue loses its diagnostic value to a great 
extent. 

In scarlet fever the desquamation may cause what is known as 
the "strawberry tongue." It is generally accompanied with des- 
quamation of the kidneys, etc. 

Depressing nervous impressions may cause a tremulousness 
and dryness that is but temporary, as in fright and great anxiety. 

Pleasurable sensations, the sight of food, etc., may induce a 
temporary humidity. "The mouth waters." 



THE ORAL TISSUES IN DIAGNOSIS. 207 

A red line, or red blotches, along the gums at a little distance from 
the margin is a diagnostic sign of pericemental or periosteal irritation. 

A still deeper red color, with excessive flow of saliva, is found in 
ptyalism, or mercurialization. 

A blue line along the gums at the margin is indicative of lead 
poisoning. 

Great spongincss, sloughing of the gums, with fetor, indicate 
scurvy. 

Dark red gums, pufhness, everted edges, with oozing of pus, are 
found in pyorrheal conditions. 

Purple gums, zvith a purulent discharge at more than one point, 
are indicative of caries or necrosis of bone. 

Gums hot and swollen, very tense, zvith a determination toward 
one point, mean suppuration, alveolar abscess, phlegmon. 

Gums inflamed and soft, with -fluctuation, indicate the pressure of 
pus, which should be evacuated. 

Szvollcn gums, fetid discharge, mucous patches, shallozv ulcers 
under the tongue, eruptions about the mouth, skin, and scalp, gums 
everted, zvith fetid matter about the necks of the teeth, the tongue per- 
haps szvollen and flabby, zvith the edges scalloped by the pressure of 
the teeth, will be found in syphilitic conditions. It should be compre- 
hended that not all these symptoms or appearances will be found 
in one mouth, but any one of them should stimulate the dentist to 
further examination and inquiry. 

The indication of imminent danger as presented by the tongue 
are a tremulous action, dryness, blueness, very red, shining, or 
glazed aspect, heavy furring, dark or black hue — the so-called 
"black tongue." 

In considering the tongue and the oral tissues as diagnostic 
organs, the indications arc not to be taken alone. The appearance 
should always be studied in connection with other symptoms, 
which may be the dominant ones, and may reverse the usual signi- 
fications. The oral tissues are to be considered as auxiliary, and 
not in every case pathognomonic. The diagnosis is to be reached 
by grouping all together, and reading one sign by the aid of the 
others. 



208 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LVIII. 
WOUNDS AND INJURIES. 

A wound is a solution of continuity in the soft parts, suddenly 
produced. It is a rupture of the tissues by some form of mechanical 
violence, and may be produced by a direct or an indirect applica- 
tion of force. 

A wound may be a complete separation, with exposure of the 
tissues to external influences, or it may be a mere contusion, with- 
out any breaking of the integument. 

Wounds have their own train of symptoms, which are usually 
quite pronounced, so that, except in certain instances of deep- 
seated injuries, their diagnosis is comparatively easy. 

Wounds are distinguished by pain, hemorrhage, loss of 
function, shock, and, in injuries of the head, concussion. 

The pain is characteristic, and is usually proportional to the 
amount of the injury. When the tissues are crushed and there is 
deep contusion, the pain is sometimes very severe. 

The hemorrhage varies greatly with the vascularity of the 
tissue affected. All wounds must have some hemorrhage, for all 
soft tissues are supplied with blood. Even in case of a wheal, 
which is merely a stripe or a ridge upon the skin, such as follows 
the cut of a whip, there is usually more or less capillary bleeding. 

Loss of function differs with the location. It may be merely 
local or it may be general, varying with the extent of the injury 
and with the tissue involved. A single small muscle may be cut, 
as for instance the extensor of one of the digits, in which case the 
function of but one finger would be interfered with; or there may 
be such laceration of the muscles of the hand as to inhibit the 
action of all the fingers. 

The amount of shock depends upon many things. The 
physical condition of the patient at the time of the injury may be 
such as to make this very profound, or there may be a high condi- 
tion of tonicity that will minimize it. The lesion may be in such 
vital organs that the constitutional disturbance will be great, or 
while considerable in extent the wound may be in tissues that 
react but feebly. The age of the patient makes a material differ- 
ence in the amount of the consequent shock, and sex is an 
important factor, women suffering from it much less than men. 



WOUNDS AND INJURIES. 200. 

Wounds are incised, lacerated, contused, punctured, per- 
forating, gunshot, or poisoned. 

An incised wound is one made with a sharp instrument. Its 
diagnosis is not always as easy as might be imagined, for a blow 
with a bludgeon may cause an incised wound if it be delivered over 
a bone with a sharp edge, in which instances the incision will be 
from beneath, and not from the surface: or the impact of a blunt 
instrument may be at such an angle as to produce a sharp rupture 
of the tissues. 

A lacerated wound is one in which the tissues are pulled apart. 
They are torn and ragged, and it is usually the result of an injury 
from compound causes, such as being caught in complicated 
machinery. 

A contused wound is one which is made with a blunt weapon. 
There is usually crushing of the tissues, without breaking of the 
skin. In such instances the connective tissue, with its enclosed 
vessels, always suffers. If but a few vessels are injured it is com- 
monly called a bruise. The hemorrhage consequent upon a con- 
tused wound is slight, and is usually limited to mere ecchymosis, 
or infiltration of blood into the tissues. The ordinary "black eye" 
is an instance of this. The extravasated blood assumes the dark 
venous hue, changes to a purplish black, then to a brownish green, 
finally assumes a yellow tint, and is absorbed. 

A punctured wound is one that is made into a cavity of the body. 
The gravity of a punctured wound depends upon the cavity that 
may be reached. Punctured wounds of the abdominal, the 
thoracic, or the cranial cavities are usually of a serious nature, 
owing to the danger of infection. 

A perforating wound goes entirely through an organ or a tissue. 
The terms perforating and punctured are occasionally confused, 
some pathologists defining punctured wounds as those made by a 
pointed instrument, and perforating wounds those which reach to 
and open a cavity of the body. 

Gunshot wounds are those made by the discharge of fire-arms. 
Works on surgery usually consider these as a distinct class, 
because of the special eon i| ilieat 101 1 S in which they are apt to be 

involved. Nol Infrequent^ in gunshot wounds foreign substances 

are carried in, Mich as portions of the clothing, debris of the 

explosion, etc. Thus the danger of infection is greatly increased, 
and the irritation produced is much more violent. The impact of 

i5 



2IO ORAL PATHOLOGY AND PRACTICE. 

bullets, from their great velocity, increases the probability of shock, 
and at the same time too often disengages splinters of bone, which 
bring on new complications. The rotation of the rifled bullet adds 
to the amount of destruction of tissue, so that the track left by its 
passage, while very difficult to follow with a probe immediately 
after the injury, is peculiarly liable to be made manifest subse- 
quently, through the breaking down of the tissue. 

A poisoned wound is one that is infected -with some mineral, 
vegetable, or animal poison. The most common of these are the 
bites of poisonous reptiles or insects, the stings of bees, wasps, etc., 
and the effects produced by the poison ivy, oak, and other toxic 
vegetables, as well as by bites of men and animals and infections by 
dirty tools. 

Wounds may be of a septic or aseptic character. In the former 
they have become infected with septic organisms, and there will be 
breaking down of tissue with suppuration, or the formation of pus. 
The septic bacteria are the greatest enemies the surgeon has to 
encounter in the treatment of wounds, and hence his chief efforts 
are directed toward the establishment of an aseptic, or sterile condi- 
tion. 

Wounds are healed by primary union, or, as it is often called, 
First Intention, by granulation or Second Intention, and by Third 
Intention. They are united by means of the fibrinous plastic 
exudate which is the result of the inflammatory process, and which 
eailier or later in the progress of healing agglutinates or unites the 
severed walls. 

Primary union or First Intention is the healing without 
infection. There is no retrograde metamorphosis, or breaking 
down of tissue. There are no acute symptoms of any kind, and no 
granulation occurs. 

Granulation, or Second Intention, is the healing of a 
wound by the regular progessive additions of papillary or 
grain-like growths. Capillary loops form at the bottom of the 
cavity of the wound, and through them new tissue is developed. 
Upon the summit of these, new capillary loops appear and new 
granulative tissue is formed, which follows the type of that from 
which it originated or to which it is to be joined, and this process 
is continued by "healing from the bottom," until the waste tissue 
is restored. 

Third Intention is the direct union of two surfaces on 



TREATMENT OF WOUNDS. 211 

which granulation has already taken place. In fact, it does 
not in essential character differ from second intention, the granular 
or capillary loops being formed in the same manner, but there is 
less of cicatricial or scar tissue as the result. 

It should be borne in mind that this system of nomenclature 
is rather arbitrary, and in part founded upon hypotheses which are 
not fully accepted by modern pathologists. All healing in one 
sense is by a kind of granulation, but as this phenomenon presents 
certain distinct phases, and as the old system of nomenclature will 
doubtless be insisted on for some time to come by State examining 
boards and others, it has been retained with this explanation. 

When granulation becomes too exuberant it may continue 
above the surface, and is then commonly denoted "proud flesh." 
Usually, when the capillary loops reach the level of the surface, the 
fibrous exudate contracts and cuts off the blood supply, and the 
process is stopped. There is a proliferation of the epithelial cells, 
or a growth of the investing tissue over it, and it is thus covered 
with the dermal appendage, and the process completed. But, as 
has been stated, this may not take place, and in that case the result 
will be a hyperplasia, or excessive formation. 



CHAPTER LIX. 
TREATMENT OF WOUNDS. 



The healing of a wound is induced and incited by cleanliness 
and an aseptic condition. In treatment the first step, in the case of 
an open wound, is to remove any foreign substances. Especially 
in incised, lacerated, and gunshot wounds should careful examina- 
tion and, ii necessary, exploration be made, to determine if any 
extraneous matter has been carried in by the instrument of Injury. 
If this is suspected, the wound must be carefully laid open to its 
extremesl point, and thorough exploration made. There can be 
no healing so long as any particle of irritating foreign matter 
remains. 

In the case of a lacerated wound, the tissues should be carefully 
examined to determine the probability of the maintenance of the 
vascular supply in them. If the blood vessels are so thoroughly 
destroyed that circulation will be completely cut off, such injured 



212 ORAL PATHOLOGY AND PRACTICE. 

tissue must be removed, to obviate the dangers of gangrene. They 
cannot recover unless they are supplied with pabulum, and this is 
carried by the arteries. Hence, if there is no chance for the 
restoration of circulation in the part, amputation or excision is 
imperative, and should not be delayed. 

The destruction of an artery or vein does not by any means 
imply that circulation is entirely prevented, for it may be carried on 
through the collateral supply. It is only when all, or nearly all, 
the communicating tissue is so injured that its vessels can no 
longer convey a supply of blood that its removal is necessarily 
demanded. 

It is not sufficient if only the interior of a wound is thus 
cleaned. The tissue about it should be carefully washed with an 
antiseptic fluid, and all foreign matters removed. If the edges are 
surrounded by hair, this must be clipped or shaved off, that it 
may not harbor any impurities, and everything that might cause 
irritation must be needfully eliminated. 

The wound should be irrigated, and thoroughly washed out 
with a disinfecting and sterilizing fluid. It is sometimes necessary 
to use a great deal of judgment in selecting this. If the injury is 
very recent it is not well to use a mercuric chlorid solution, 
because this may induce mercurial poisoning. Nor should carbolic 
acid or iodin be employed, as they may bring about carbolic or 
iodin poisoning. Preparations of hydronaphthol, formalin, or boric 
acid are preferable. If, however, there is an infected condition and 
pus is present, the stronger germicides, like mercuric chlorid I part 
to from 2000 to 4000 parts of water, may be employed. 

No operations about a wound are permissible without the most 
stringent antiseptic precautions. All the sponges and cloths used 
must be sterilized. The hands of the surgeon must be thoroughly 
washed with aseptic soap, all matter under the nails being removed, 
and finally they must be drenched with an antiseptic mixture, or 
washed with ground mustard used in place of soap. 

A broad and shallow vessel partly filled with a solution of car- 
bolic acid, hydronaphthol, formalin, or some other good anti- 
septic, should be provided for all instruments used, and these must 
frequently be dropped into it. Especially if any instrument or 
sponge should happen to come in contact with any unsterilized 
body, as by an accidental dropping upon the floor, must it be given 
a bath in the sterilizing tray. 



TREATMENT OF WOUNDS. 213 

If the hemorrhage from a wound is light in color, or if it issues 
by distinct spurts, it is arterial. If dark in color and steady in its 
flow it is venous; if merely oozing it is capillary. Either may be 
controlled by means of the hemostatic forceps, and by ligatures. 
Enough of the former instruments should be kept in the sterilizing 
solution for any emergency. With one of these the mouth of a 
bleeding artery or vein is seized, the handles are locked, and it is 
allowed to remain in position until the close of the operation. . If 
the bleeding has not then been stopped by the contraction of the 
muscular coats, a ligature may be passed about the vessel and the 
ends allowed to protrude from the wound. 

When the bleeding is capillary, it may be necessary to pass a 
ligature around a portion of the tissue for the purpose of arresting 
it. When it is venous, it is sometimes sufficient to seize the 
mouths of the vessels with one pair of artery forceps, draw them 
out sufficiently to allow of grasping them with a second pair, and 
then to accomplish torsion by twisting. 

For controlling the hemorrhage caused by the severing 
of important arteries, the only effective means is the liga- 
ture, the application of which sometimes demands expert 
knowledge and judgment. Great injury may be done by unskill- 
ful ligation. In the larger vessels, the arteries, veins, or nerves 
may be within the same sheath, which is but an enfolding of the 
fascia; and there may be more than one vein. .Before ligating, the 
sheath should be opened and the vessel to be tied dissected out. 
The ligature should be passed about it, and fastened with a square 
knot to prevent slipping. The knot should be drawn firmly, but 
not too tight, lest the outer coat of the vessel be cut, and sloughing 
and secondary hemorrhage be the result. An artery should not 
be drawn out of its sheath any farther than is necessary to allow of 
tying, because in so doing its future nutrition may be interfered 
with, through separation .of or injury to the vaso-motor nerves. 

Immediate or mediate compression may be used for stopping 
the flow of blood temporarily when it is excessive. 

Immediate compression is accomplished by packing the 
wound with lint, and then applying a compress or bandage. 

Mediate compression is when pressure is made upon the 
arter) between the wound and the heart. Any firm substance is 
placed over the artery, and then a bandage or tourniquel is twisted 
Y<T\ firmly about the pari until the bleeding is controlled. 



214 <»RAL PATHOLOGY AND PRACTICE. 

The control of bleeding by acupuncture is sometimes neces- 
sary in aged persons, the muscular coats of whose arteries are too 
weak to withstand the ligature. This consists in transfixing the 
tissues with an acupuncture needle, and then winding about it a 
ligature in such a manner as to produce local compression. 

Aneurisms may be formed through injuries to arteries, 
when some of their coats are divided and there is dilata- 
tion of those which remain unpunctured. In their earlier 
stages aneurisms may be diagnosed by the distinct pulsations 
within them, but later this may be masked by the thick felt of blood 
coagulum which forms within. A tumor in the immediate neigh- 
borhood of an artery should be opened with extreme caution, lest 
it prove of an aneurismal character. 

The ligating of an artery, when skillfully done, does not 
deprive the tissues dependent upon it of their vascular supply, as 
sufficient collateral circulation is soon established. This takes 
place through an enlargement of the communicating and anasto- 
mosing smaller arteries given off above and below the wound, 
until they are sufficient to convey the volume of blood originally 
carried by the divided vessel. 

A wound having been cleansed and irrigated, and the hemor- 
rhage having been completely controlled, the next step is to close it. 
If the gaping is considerable, it may be necessary to sew it up. 
This is done with sutures of catgut if it is deep, or with silk if more 
shallow. The stitches are made with suture needles of differing 
shapes, which may be passed by means of needle forceps. All 
ligatures or sutures must be thoroughly sterilized before using. 
The depth of the stitches must be proportioned to the depth of the 
wound. If this is considerable, it may be advisable first to insert 
a few catgut sutures to hold in place the deeper tissues. The final 
closing ones are always superficial, and they should be near enough 
together to prevent any gaping of the edges. The closing stitches 
should be carefully made, so that there will be no drawing of the 
integument, the borders of the wound being left in smooth coapta- 
tion. They are to be removed as soon as there is sufficient union 
to prevent the separation of the edges. This will be within a very 
few days, if all goes well. Sometimes it is necessary to use deep 
retentive sutures to prevent undue tension upon the closing 
stitches. They have their insertion at some distance from the 
margin of the wound, and each end is attached to a button, so that 
they will not be likely to cut through the tissues. 



TREATMENT OF WOUNDS. 21 5 

If the wound has become infected with septic organ- 
isms, or if there is good reason to suspect that it will be im- 
possible to keep it aseptic, it may be necessary to insert a 
drainage tube before completely closing it. This may be of 
sterilized rubber, or of decalcified bone; or it may be only some 
strands of silk or gauze, carried to the deep portion of the wound 
and allowed to come to the surface; and its size should be propor- 
tioned to the amount of probable discharge. The drainage tube 
offers a ready means of escape for pus or sanious matter, secretions 
of glands, or the products of inflammation. If the tube penetrates 
to a cavity of the body, some effective means, like a ligature or the 
insertion of a safety pin, must be employed to prevent its being 
drawn into the cavity. To retain it and keep it from slipping out, 
it may be held by the external dressings, by adhesive strips, or 
other convenient means. The drainage tube is to be left in place 
as long as there is a necessity for its presence. Sometimes it is of 
great convenience in irrigating or washing out the wound. 

The final dressing of a wound should be with antisep- 
tics. After terminal washing and cleansing of the exterior with an 
antiseptic fluid the surface is usually dusted with aristol, acetanilid, 
or iodoform. A piece of antiseptic gauze is then superimposed, 
and npon this sterilized cotton batting, in quantity sufficient to 
make a thick pad. The wounded organ may then be bandaged, 
and placed in a sling or support if required. The dressings may 
be removed when necessary, but should not be disturbed by med- 
dlesome interference. 

Poisoned wounds that are of a serious character, such as the 
bites of venomous serpents, should be immediately ligated to pre- 
vent the spread of the poison in the blood, and then be thoroughly 
cauterized. The latter may be effected by the actual cautery or 
by cauterizing agents like silver nitrate or chromic acid. An 
effectual though not agreeable way is to burn gunpowder upon 

the WOUnded Surface. This may be practicable in ease of accidents 
when no Other cauterizing agent is at hand. 

The after treatmenl of wounds consists in the exercise of the 
most watchful care to avoid septic infection, or to combat it when 
present. .All dressings must be kepi clean and in place, and 

changed if necessary t" accomplish this. But meddlesome inter- 
ference musl be avoided, and no dressing should be removed unless 
thi re is good cause for it. When the organizable lymph has been 



2l6 ORAL PATHOLOGY AND PRACTICE. 

effused it must be protected and kept aseptic. Every sanitary 
precaution should be observed, and the patient sustained with a 
nourishing diet. A wounded limb must be kept quiet and 
muscular action prevented, except so far as motion of joints, etc., 
is required to prevent ankylosis. 



CHAPTER LX. 
EXCESSIVE BLEEDING. 



There is nothing in dental practice that is more alarming, 
especially to the young practitioner, than to have follow an opera- 
tion an unusual flow of blood which cannot readily be checked. 
Too many lose their presence of mind at such times, become con- 
fused and distracted, exhibit this in their manner, and thereby alarm 
both patient and attending friends. A physician is perhaps called, 
who assumes direction of affairs, and the dentist is relegated to a 
subordinate position. As a consequence he is humiliated and loses 
the confidence of all who are witnesses. Exaggerated accounts of 
the matter are circulated from mouth to mouth, and his profes- 
sional reputation may thus be irretrievably injured in the commu- 
nity. All this may at any time be the consequence of lack of 
knowledge, or a deficiency in professional self-confidence. In any 
sudden emergency the most important requisite on the part of the 
doctor is self-possession, and the entire command of his own 
powers. 

The first thing to consider in cases of hemorrhage is whether it 
is arterial, venous, or capillary. If the former, the blood will be a 
bright red, and will issue from the wound in jets, synchronous with 
the heart-beats. If it is venous, the blood will be darker in color 
and will well up continuously. If it is capillary, there will be a 
slow oozing from the edges, which will appear again as it is wiped 
away. This, while the least alarming in appearance, is really the 
most threatening, because it may be the result of a hemorrhagic 
diathesis. 

Arterial bleeding may always be checked by ligation of the 
artery. Usually, however, unless the vessel is an important one, 
it will be sufficient to wipe away the blood with a sponge until the 
mouth of the severed vessel is found, when it should be grasped 



EXCESSIVE BLEEDING. 21? 

with a pair of artery forceps, which are at once locked upon it. In 
their absence the mouth of the artery or vein, with a little of the 
surrounding tissue, may be seized with any suitable pliers, and the 
whole twisted and pinched until the coats of the vessel contract 
sufficiently to stop the bleeding. Sometimes a waxed silk ligature 
passed around it and closely tied is preferable. 

If the bleeding is from the socket of an extracted tooth a 
pledget of cotton, or lint, or sponge that has been dipped in tannic 
acid, or, in its absence, in powdered alum, or red pepper, or in a 
solution of iodin, turpentine, capsicum, or even dilute sulphuric 
acid, should be closely packed at the bottom, and on that a cork, cut 
to a conical form that shall fit the socket, should be placed in such a 
manner as to project sufficiently for the occluding tooth to shut 
firmly upon it. A two-tailed bandage may be now used to firmly 
press up the lower jaw and hold the cork in position. This should 
be left for some hours at least, when the bandage and cork may be 
carefully removed, leaving the cotton until it loosens itself. 

If the bleeding is distinctly venous the same methods may be 
employed, but the emergency will not probably be as great. Arterial 
bleeding will be certain to receive attention, but the smaller veins 
may continue open, and there may be a steady loss of blood for 
hours, which will gradually weaken the patient. If this is the 
case, an examination should be made to determine whether the 
bleeding is from the small veins or is distinctly capillary. If the 
former the points of its issue may be readily determined, but if it is 
the latter there will be a slow oozing from the tissues without any 
distinct point of exit. 

If it is capillary hemorrhage, the condition will demand the 
most care and cause the most anxiety. Strips of cotton wet with 
a tannic acid solution or a ten per rent, solution of antipyrin, 
or with one of the other hemostatics named, should he adjusted 
over the wound, if on the surface, anil bandaged to place if 
possible. Monsell's solution of perchlorid <>f iron should not be 
used in the month, nor should any active cauterants In- employed. 
Tannic acid, in doses of one to four grain-, may he administered in 
water every two hours in extreme cases. Or, of the aqueous 
extract of erigeron from five to ten -rain- may he administered 
every two hours. ( >r from fifteen to thirty drops of tinrt. of ergot 

may he given every hour until the bleeding ceases. The feet 

should also he placed in hot water for half an hour. Ycratnun 



2l8 ORAL PATHOLOGY AND PRACTICE. 

viride, as an arterial sedative, in doses of two to five drops every 
two hours, will frequently prove useful. 

In the so-called hemorrhagic diathesis the tendency toward 
capillary Weeding- is due either to some abnormal condition the 
result of a distinct dyscrasia, or to a lack of tone in the system. It 
seems to be idiosyncratic with some. When either of these is the 
cause it may demand more than a general knowledge of the sub- 
ject, and the family physician should be called to learn whether 
there exists any special cachectic condition. If this is the case it 
will, of course, be turned over to him. Anemia, purpura, scrofula, 
typhoid, and other diatheses tend to induce excessive bleeding, 
and in their presence great care should be used. If there is any 
special idiosyncrasy the patient will probably know of it, and 
should warn the dentist before any operation is commenced. 



CHAPTER LXI. 

FRACTURES AND THEIR TREATMENT. 

The consideration of fractures should properly be taken up in 
connection with surgical procedures. But, as cases of injury to 
the jaw and head may at any time fall into the hands of the dental 
practitioner, this work would be incomplete if their pathology was 
not in an epitomized manner given some attention. More than 
this is not attempted. 

A fracture is a solution or rupture of continuity in bone or 
cartilage. What wounds are to soft tissues, such are fractures to 
the framework of the body. They form one-seventh of all the 
injuries to which human beings are liable. They are ten times as 
frequent as dislocations. They are of all degrees of severity, from 
the mere indentation or irregular depression of a flat bone to the 
complete comminution of long bones. The character of the frac- 
ture will depend upon the force which produced it and the shape of 
the bone itself. Thus, in irregular bones the fracture is usually a 
compression, while in long bones it is likely to be a complete 
separation, with more or less displacement of the fragments. 

Fractures may he produced by external violence or by internal 
muscular action. Probably a much greater proportion of them are 
caused by the latter than would be readily imagined. 



FRACTURES AND THEIR TREATMENT. 2IO. 

t 

The strength of bones, and therefore their ability to with- 
stand injuries, depends upon their texture. Compact tissue is 
stronger than that which is cancellous, and the bones of different 
individuals greatly vary. So also does the strength of a bone 
alter with the physical condition, certain diatheses predisposing to 
weakness, until perhaps in some extreme instances they yield to 
comparatively slight muscular exertion, and break almost spon- 
taneously. The shape of bones has also much to do with their 
strength, the long and flat being more liable to fracture than the 
irregular. 

The bones of males are stronger than those of females, but 
they are more exposed to accident. Age has much to do with the 
resisting power of the different parts of the skeleton, those of older 
people being more brittle. Weak points, or curves, largely deter- 
mine the course of fractures, especially when they are the result 
of muscular action. 

Fractures may be Simple, Compound, and Complicated. 

A simple fracture is one in which the skin or mucous membrane 
is not ruptured, and there is no serious injury to the investing tissue. 

A compound fracture is one in which there is a communication 
through the skin, or exposure of the bone to the air, with the f >ssibility 
of infection. 

A complicated fracture is one in which other tissues arc involved 
in the in jury. 

Fractures are also Complete and Incomplete. 

A complete fracture is one in which there is a separation of 
the body of the bone into two or more fragments. Complete frac- 
tures may be dn ided as follows: 

A Transverse Fracture is one that is at right angles to the axis 
of the 

Au Oblique Fracture is one that is at an angle oj leu or more 
degrees. 

. I Longitudinal Fracture is one that is at an angle oi more than 
seventy degrees. 

. In Epiphyseal Fracture is a fracture of the cartilage which unites 
/In- epiphysis, or extremity, to the shaft of a luoie. Of course it can 
only occur in young persons. 

A Multiple fracture is one in which the bone is separated into a 
number of fragments. 

. In I inputted Fracture is when ton- fragment penetrates another, 
thus preventing their free movement. 



220 ORAL PATHOLOGY AND PRACTICE. 

A Comminuted Fracture is one in which the bone is shattered, or 
separated into fine particles. 

An incomplete fracture is when there is not an entire separa- 
tion of the body of the bone, but either it stops short of that or 
consists in the breaking 1 off of a portion. Incomplete fractures may- 
be classified as follows: 

A Fracture of the Apophysis is the separation of that process 
from the shaft. 

A Detached Fracture is the separation of a fragment, as by a 
cutting instrument. 

Fracture of the Malleolus is a separation of the hammer-shaped 
head of a bone, the body or shaft remaining intact. 

A Green-stick Fracture is what its name indicates: the splintering 
of a bone without its entire separation. This is necessarily mainly 
confined to long bones, and to young persons. 

A Fissured Fracture is the opening of a crack in one plate of a 
bone, as in certain fractures of the crania. 

A Depressed Fracture is when a dent is made in the table of a 
bone, a part being thus displaced without entire separation. 

The diagnosis of fracture, although usually easy, may be ex- 
ceedingly difficult. The symptoms presented are both objective and 
subjective. They may be arranged under the following heads; 

History of the predisposing or immediate cause. This should 
always be carefully inquired into, especially if the force seems 
inadequate to the production of the injury. 

Localized pain and tenderness. This may be determined by 
pressure and digital manipulation. 

Crepitus. This is the grating of one fractured end upon 
another, and is determined by careful movements of the parts. In 
impacted fractures this means of diagnosis is eliminated, and hence 
it may be difficult to arrive at a conclusion. 

Abnormal mobility. It is sometimes almost impossible to 
determine this in the neighborhood of joints, unless crepitus is 
present. 

Deformity. This may be partially or completely masked by 
the swelling consequent upon the injury. 

Comparison of two sides. This is very important in determin- 
ing the deformity, but a possible asymmetry may lead one astray, 
unless caution is used. 

When the deformity is reduced it will not remain so, but the parts 



FRACTURES AND THEIR TREATMENT. 221 

will separate and reproduce it. This will distinguish a certain class 
of luxations from fractures. 

Anesthesia is sometimes necessary in making a diagnosis, 
owing to the resistance of muscular action. 

Treatment of Fractures. 

Bones very readily unite when their injuries are properly 
treated. Reduction is the first thing to be accomplished. If 
there are no complications, and if the fractured ends are firmly 
held in apposition, there will be a deposit of plastic lymph — in this 
instance usually called provisional callus — about the injured ex- 
tremities. This assumes a cartilaginous form, and in due time 
ossifies and firmly unites the fragments, the process demanding 
from four to eight weeks. There will necessarily be some tem- 
porary enlargement and deformity, which will greatly depend upon 
the amount of displacement. In time, as the newly formed tissue 
becomes fully organized, the projecting portions will be resorbed, 
and the irregular surfaces thus made more symmetrical. 

Before the final reduction any muscular injury must be at- 
tended to, and if there are complications, such as involvement of a 
joint or injury to a contained organ, or comminution of the bone, 
these must be looked after. 

The greatest obstacle to reduction and retention will be the 
muscular contraction consequent upon the injury. This must be 
controlled by traction and counter-traction. A steadily applied, 
moderate force must be brought to bear upon the muscles until 
they gradually yield. Violence will only increase the contraction, 
but a gentle, persistent force, like that of a weight, will after a time 
tire the muscles out, when they will readily give way. 

( >blique fractures usually need only extension for their reduc- 
tion. Transverse fractures with displacement require also manipu- 
lation. 

When reduction is accomplished, the parts are usually held in 
place by splints or bandages. Absolute immobility is not required, 
as slight motion is beneficial, owing to the fact that it is a stimulus 
to functional activity. 

In the treatment of compound fractures, the wound 
must be considered as an open one, and the instructions 
given in Chapter LIX., Treatment of Wounds, should be 
kept in mind. Thorough asepsis must In- secured it" possible. 



222 ORAL PATHOLOGY AND PRACTICE. 

An anesthetic may be administered and the injury thoroughly ex- 
plored for the removal of all comminuted fragments, blood-clots, 
and foreign matter. A drainage tube may be inserted if desirable, 
and the wound left open at its center. 

Delayed union, or non-union, may exist when the plastic exu- 
date is not promptly thrown out, or being deposited is not organized. 
Perhaps the circulation or nutrition is impaired. This condition 
should be attentively looked after. The ends of the bone may be 
rubbed together if necessary, to stimulate functional activity. 

Delayed union may result in the formation of a " false 
joint," or a fibrous union. In such instances it will be neces- 
sary to break this up, and perhaps to bore the ends of the bone, or 
scrape them, to induce a new osseous formation. 

Non-union may be the result of a neglect properly 
to reduce the fracture. The ends of the bone may become 
rounded off by resorption and the medulla be closed. The remedy 
in such instances is to open the seat of the fracture, saw off the ends 
of the bone, and depend upon a new formation after reduction. 

In fractures of the long bones, shortening is likely to be the 
result of muscular contraction and the overlapping of the ends of 
the fragments, unless extension is used. 



CHAPTER LXII. 
SPECIAL CASES OF FRACTURE. 

Fractures of the nasal bones may be determined by the deform- 
ity, by the infiltration or emphysema of the investing tissues, by 
crepitus, and through obstruction of the nasal passages by blood- 
clots. They are not dangerous unless the injury is at the base, 
when the cribriform plate of the ethmoid may be injured, and a 
shock thus given to the brain. The adjustment must usually be 
by means of directors or needles thrust up the nostril, and the 
parts are held in place by adhesive strips. 

Fractures of the superior maxilla and of the alveolar process 
may be met with. If they are incomplete and there is no special 
deformity they have little significance. The nasal and alveolar 
processes are frequently broken. The former may be a complica- 
tion of injuries to the nasal bones. The latter may be broken in 



SPECIAL CASES OF FRACTURE. 22$ 

careless extraction of the teeth. It very readily unites, and usually 
requires little attention unless a small fragment is displaced, in 
which case it should be removed. 

Fractures of the body of the superior maxilla may result from 
great violence. There is no bone which so readily unites, and all 
that is usually necessary is to reduce the fracture as completely as 
possible, and retain the parts in apposition by bandages and ad- 
hesive strips. When the injury is considerable, the adjustment 
may sometimes be made by getting the teeth in alignment, and 
retaining them by ligatures, gold bands, or even an artificial palatal 
plate. 

The antrum may be involved in fractures of the superior 
maxilla, and this may introduce a complication that may embarrass 
the treatment. In such a case the directions given in the chapter 
(XXXV.) on Diseases of the Maxillary Sinus should be observed. 

The hemorrhage in fractures of the maxilla is not usually 
serious, and it will not be difficult to control. 

Fractures of the inferior maxilla are three times as common as 
those of the superior. This is because of their increased liability 
to accident through their greater exposure. • The fractures are 
most often those of the body, although the ramus may be the seat 
of the injurw 

The diagnosis is easy, except when the injury is to the coro- 
noid process or the ramus. The symptoms are pain, deformity, 
mobility, and crepitus. The teeth form a most important auxiliary 
in both diagnosis and treatment. Observation of the position of 
the jaws and the occlusion of the teeth, if the latter are present, will 
ordinarily be sufficienl to determine the amount of injury and the 
best method of reduction. 

The treatment of all such cases is best accomplished by the 
dentist, because he is familiar with the normal condition of the 
organs involved, and he has the mechanical skill to construct the 
appliance which will best reduce the displacement and retain the 
fragments in proper apposition. Too often the proper function oi 
the teeth is losl through lack of the knowledge how to secure their 
proper alignment, or ^<> to retain the fragments thai normal occlu- 
sion will be secured when healing is complete. 

Various forms of splints have been devised by ingenious 
dentists for the treatment of fractures of the inferior maxilla. 

Some have held the fragments in apposition with the upper jaw by 



224 ORAL PATHOLOGY AND PRACTICE. 

banding the opposite or occluding teeth on each side of the line of 
fracture, and then holding them together firmly by means of a 
connecting screw or clamp. 

Various devices for wiring the teeth together have been pro- 
posed. The general surgeon has in the past mainly depended upon 
this method of retention. 

Skull caps, with fixed or elastic bandages passing around the 
lower jaw, have been employed. 

But perhaps the most effectual method is the employment of 
some form of the interdental splint. An impression of the frac- 
tured jaw is taken in some plastic material, without any attempt at 
replacement of the fragments. A cast of this is made in plaster-of- 
Paris, which gives a counterpart of the deformed jaw. Another 
impression and cast of the occluding jaw and teeth is secured. A 
fine saw is run through the cast of the broken jaw at the point or 
points of injury, and the pieces placed in proper apposition with the 
cast of the superior teeth, when they are fastened by running 
plaster-of-Paris about them. They are placed in an articulator 
and a wax model of a splint is made for the lower jaw which will 
properly occlude with the teeth of the upper jaw, so that mastica- 
tion may be possible during the process of healing. 

The wax model is reproduced in vulcanite, and when the frag- 
ments of the broken jaw are adjusted to it they may be retained in 
various ways. In the case of one such fracture of the jaw of a 
noted pugilist treated by the author, which had remained unre- 
duced for some weeks, nothing more was needed than the insertion 
of four gold screws through the outer plate of the splint, which 
obtained their hold in the V-shaped space between two teeth that 
were close together. Although this case demanded a subsequent 
operation from the outside for the removal of comminuted frag- 
ments, it was not found necessary to remove the splint until healing 
was complete. 

In another case, one of fracture of both the upper and lower 
jaws in a boy of fourteen, the splint consisted of a gutta-percha 
impression of each jaw, trimmed to proper shape. After their prep- 
aration, and immediately before their insertion, the occluding sur- 
faces were warmed so that they would adhere together when reduc- 
tion was accomplished, an elliptical opening between the anterior 
teeth being made for the purpose of feeding. The adjusting of the 
parts and the insertion of the splints, with the necessary band- 



DISLOCATION'S AXD SPRAINS. 225 

aging, was accomplished under chloroform. The whole work, in- 
cluding the taking of the impressions, the fashioning of the splints, 
and the reduction, occupied less than an hour, although three very 
competent physicians and an accomplished surgeon had vainly kept 
the boy under an anesthetic for more than four hours previously. 
Their failure was solely clue to their inability to construct a splint 
that would hold the parts in apposition when they had the different 
fractures reduced, and not of course to any lack of surgical skill or 
knowledge. 

The judicious and ingenious dentist will readily devise 
an appliance that will be sufficient to retain the fragments 
in any form of injuries to the jaws. No two cases present 
precisely identical conditions, or require the same treatment, and 
he will vary his appurtenance so that it will meet the required ends. 

It is no part of the scope of this work to give instructions for 
the mechanical manufacture of splints, interdental or otherwise. 



CHAPTER LXIII. 
DISLOCATIONS AND SPRAINS. 

A Dislocation is the complete or partial separation of the articu- 
lar surface of one bone from that of another, or the displacement 
of an organ from its natural position. 

Joints or articulations are movable and immovable, or fixed. 

//' movable, they are complex in their structure and arc united by 
flexible ligaments. 

If slightly movable, they arc usually connected with fibro-cartilage, 
which is tough, elastic, and pliant. 

If immovable, they are connected by mere membranous sutural 
ligaments. 

Sometimes the union of fibro-cartilage is so firm that onlj a 
fracture can cause displacement. 

The ends of articulated bones, if the joint is a movable one, 
arc enlarged and made up of compacl tissue, the lamellae differing 
from those of tlu- other parts, being witliMut Haversian canals. 
The nutrition thus being less complete, they arc more apl to die. 

Articular cartilage covers the ends of hones, and, as has been 
said, fibro-cartilage separates certain of the joints, such as the 

[6 



226 ORAL PATHOLOGY AND PRACTICE. 

vertebrae. A man is half an inch taller in the morning than at 
night, because during the day, when he is in an upright position, 
the interarticular fibro-cartilage becomes compressed. 

A ligament is a band of compact membranous tissue connecting 
the articular ends of bones, and sometimes enveloping them in a capsule. 
It is not the office of the ligament to hold the bones together; 
that is the function of the muscles, the ligament merely limiting 
and restraining the motion, preventing it from going too far. 

The synovial membrane is a short membranous tube enclosing the 
joint, attached at the edges of the cartilage, and secreting the synovia, 
or synovial fluid, for the lubrication of the joint. 

When there are many muscles and great flexibility is de- 
manded, as in the wrist, there is very seldom a dislocation. 

Dislocations are traumatic, pathological, or congenital. 

Traumatic dislocations are the result of external violence or of 
muscular action. They are by far the most frequent of any. 

Pathological dislocations are the result of the destruction of a 
part of the articulation by disease. 

Congenital dislocations are those in which some essential part of 
the joint has never developed, and hence they are irreducible. 

Dislocations, like fractures, may be simple, or compound, or 
complicated. 

A simple dislocation is one in which there is displacement, without 
injury to any tissue. 

A compound dislocation is one in which there is a wound that 
exposes some part of the articulation to the air. 

A complicated dislocation is one in which important nerves, blood- 
vessels, or other tissues are involved in the injury. Complicated dis- 
locations are fortunately infrequent. 

The symptoms of dislocation are much the same as those of 
fracture. They are as follows: 

Deformity. This will be evident from the unnatural position 
of the bone, and from the tumor which will be the result. 

Pain. This may be quite severe, and it will be located at the 
position of the joint. It will probably be of a dull, sickening 
character, and it is worse than that of a fracture. 

Rigidity. This will arise from the fixation of the parts, the 
voluntary movements being entirely absent or very much limited. 

New position of the bone. This may often be traced through 
the tissues by digital, or even, in some cases, ocular examination. 



DISLOCATIONS AND SPRAINS. 227 

The axis of the bone is altered and all its relations are modified. 
Usually there is lengthening or shortening, as in fractures. 

Dislocations are differentiated from fractures by the immo- 
bility of the former, the absence of crepitus, and by the general 
appearance, the character of the pain, etc. 

Dislocations are treated first by reduction. This is best 
secured by manipulation, whenever that is possible. 

If the ligaments are badly torn and the luxation is thus com- 
plicated, manipulation may cause exceeding pain, and an anesthetic 
may be necessary. 

Sometimes in old dislocations there have been exudation and 
partial organization of the product, with perhaps more or less of 
bony ankylosis; or, more probably, fibrous ankylosis may have 
been formed, so that it is impossible to obtain reduction without 
surgical help. In these cases it may be necessary to open the joint 
and break up the union. This must, of course, be done under the 
strictest antiseptic precautions. 

Dislocation of the inferior maxilla may be unilateral, involv- 
ing but one side, or what is more frequent, bilateral, with forward 
displacement. It consists in a slipping forward of the condyle from 
the glenoid fossa, over the eminentia articularis. It occurs only 
when the mouth is widely opened. The external pterygoid muscle 
becomes violently flexed, and draws the condyle forward upon the 
surface of trie bone. The temporal muscle becomes rigid, and 
helps to hold the condyle in its false position. The interarticular 
cartilage is carried forward with the condyle, but the capsular 
ligament is not usually torn. 

The symptoms of luxation of the inferior maxilla are a rigidity 
of the jaw, with inability to move it or to close the mouth. There is 
a marked projection of the chin, and the condyle may be felt for- 
ward of its normal position. If it is unilateral there is a deviation 
of the jaw toward the uninjured side. 

The reduction of the dislocation is effected by support- 
ing the symphysis, and at the same time depressing the 
angles of the jaw, the object being to carry the condyle 
downward and backward until it will slip over the articular 
eminence. The operator should stand in front of the patient, 
and, the thumbs being protected by wrapping around them a 
handkerchief, the jaw is firmly grasped with both hands, the pro- 
tected thumbs being placed far back over the molar teeth. Then, 



228 ORAL PATHOLOGY AND PRACTICE. 

by pressing down with the thumbs and supporting the symphysis 
with the ends of the fingers, the jaw may usually be carried to 
place, the condyle slipping into the glenoid fossa with a distinct 
snap, and the jaw closing with considerable violence. 

Sometimes it may be necessary to use a round piece of wood 
between the back teeth as a lever to carry the condyle down and 
back, the angle being supported with the hand. This method will 
be found especially useful in unilateral luxations. Some kind of a 
pad should always be placed between the - teeth of the two jaws, to 
prevent their being broken with the violence of the closure when 
the reduction is made. 

Dislocation of the lower jaw backward sometimes occurs, but 
only as the result of great violence, and is necessarily accompanied 
by fracture of the borders of the fossa. The dislocation in this case 
becomes of less importance than the other injury, and its reduction 
is subordinate to the other treatment. 

A Sprain is a self-reduced dislocation, with consequent soreness 
from the violent strain upon the muscles and tendons, and with pos- 
sible laceration of the ligaments or attachments. It is characterized 
by severe pain, much increased by movement, with rapid swelling 
and heat in the joint. Sprains are usually treated by either hot 
fomentations or cold applications, whichever seems indicated. 
The former will be likely to bring about resolution, while the latter 
will be demanded when there is a great deal of heat and an intense 
hyperemia. If the swelling is very great, through excessive effu- 
sion, it is well to bandage with cotton, and to secure immobility by 
means of a plaster-of-Paris bandage, after the swelling shall have 
subsided. 



CHAPTER LXIV. 
SHOCK— COLLAPSE. 



Shock is the depression that is caused by severe injuries, surgi- 
cal operations, or great mental disturbance. It is the result of 
reflex nervous action, and may be slight, like the temporary faint- 
ness which soon passes away, or so severe as to induce a vital 
depression that is almost instantaneously fatal. It has already been 
shown that it is not the bullet in the heart that kills, but the impres- 
sion upon the whole nervous system which is its consequence. In 



SHOCK COLLAPSE. 229 

such an instance the shock is the direct result of the impact. But 
no less fatal may be the indirect effects of a mental impression. It 
is related that the janitor of a medical school had made himself so 
obnoxious to the students that even his life had been threatened. 
As the result of a conspiracy among them he was captured one 
night, conveyed to a sepulchrally draped room, shown a block and 
ax, and informed that he was to be executed. Amid the solemn 
and impressive surroundings he was seized by the masked men, 
his neck bared and placed upon the block, when the executioner 
struck with a towel wet in ice-water. The victim was taken up 
dead. The shock was as complete as though the actual ax had 
been used. 

There is a wide difference in the susceptibility of different 
persons to shock. Some are of an emotional nature, and compara- 
tively slight mental impressions of a depressing kind produce pro- 
found effects. Others are more stolid and apathetic, and lose their 
nervous equilibrium less readily. It is well known that an unim- 
portant mishap will, in some instances, produce fatal effects, while 
in others the system will successfully withstand the gravest 
injuries. The immunity of drunken men to the results of accident 
is proverbial. Their intoxication so exalts or stupefies the nervous 
system as to fortify it against or exempt it from shock, the usual 
result of injury. 

The shock that is caused by mere mental impression is more fre- 
quent and often more profound than that produced by actual vio- 
lence. Especially is this the case with nervously susceptible people. 
The mere sight of a dentist's instruments too ostentatiously 
paraded may induce a depression and shock to a nervous female 
that will be absolutely more Injurious than the contemplated opera- 
tion. Any incivility of manner or unnecessary roughness of 
method on the pari of the operator may, to a timid child, be worse 
than the real pain, because it can induce a more profound shock. 
In the lighl i »f tlie.se truths it is eas) to ci imprehend \\ h\ the gentle, 
suave, sympathetic dentisl is able to perform with comparative 
case to the pati< m operations thai another finds absolutely imprac- 
ticable. 

It is because of the limiting of the primary shock that 
operations under the influence of an anesthetic are possi- 
ble and safe, that otherwise would be fatal. The benefi- 
cence of these agents and the glory of the discover) of anesthesia 



23O ORAL PATHOLOGY AND PRACTICE. 

is not confined to the immunity from pain which they give, but 
they have saved lives almost innumerable through their making 
feasible operations that before were impracticable. 

The usefulness of prophylactic remedies, to be employed 
before dental or oral operations, lies in their ability to pre- 
vent shock to the nervous system, either by stimulating it 
so that it can successfully withstand disagreeable impres- 
sions, or so stupefying it as to make it insensible to them. 
In either case the primary shock is correspondingly lessened or 
inhibited. The entire confidence of a patient once secured, 
especially that of a child, the nervous system will without injury 
undergo, or even be insensible to, pain that under other circum- 
stances would be unbearable, because the deadly influence of 
shock is avoided. It may readily be conceived, then, that the 
subject is of paramount importance to the operative dentist, and 
that it is his bounden duty to study it with care. In this connec- 
tion, the remarks upon nervous influence in the chapter on Hyper- 
sensitive Dentin will be found useful. 

The distinction between shock and collapse is one not easily 
made plain, nor is it necessary here to draw a fine discriminating 
line. It is sufficient if we consider shock as the result of either 
mental or physical violence, while collapse is the final consequence 
of continued exhaustion. Thus the impact of a bullet may induce 
shock, but the slow bleeding that may succeed it will finally end in 
collapse. 

Shock may not only be the result of different kinds of injury, 
physical or mental, but it may assume different forms. For con- 
venience these may be classed as torpid, excitable, and delayed. 

In torpid, or apathetic, shock the symptoms may be 
almost entirely referred to vaso-motor paralysis. The circu- 
lation is materially modified. There will be a pallor of the skin 
and of the mucous membrane, with coldness, especially of the 
extremities, and the patient may be covered with a cold perspira- 
tion. The expression of the face is changed or lost, the pupil of 
the eye is dilated and does not respond readily to light. There 
is irregularity of the action of the heart, with a weak, thready, 
and perhaps almost imperceptible pulse. The respiration becomes 
slower and more superficial. There may be partial or complete 
insensibility, mental inactivity, and loss of control of the voluntary 
muscles. There will be depressed bodily temperature, perhaps to 



SHOCK — COLLAPSE. ' 23 1 

be followed by a corresponding rise, and in some instances nausea, 
and possibly vomiting. 

In excitable, or erethistic, shock the patient is restless, 
irritable, easily disturbed, perhaps uncontrollable. There 
is found a disordered pulse, with irregular breathing and dilated 
pupils. Notwithstanding the actually depressed condition, there 
will be the appearance of unnatural activity. The sufferer may 
perhaps exhibit an impatience with and opposition to the institu- 
tion of the proper remedial measures, or the continuance of any 
necessary operation. To the operative dentist, these symptoms 
are often premonitory of a more profound impression, and are not 
to be disregarded. Upon their appearance he should use 
redoubled care to avoid further nervous injury, and should 
promptly administer an anodyne. 

Delayed shock is the condition in which the symptoms 
are only manifested some hours after the injury or nervous 
impression has been received. They do not materially differ 
in reality, and may be of either the torpid or the excitable char- 
acter. They may be the result of a slow and concealed hemor- 
rhage. This type is often observed after dental operations that 
were not of a serious nature, but which were considerably pro- 
longed. The patient probably has not incurred any material harm, 
aside from the bodily depression that ensues, and the character of 
the symptoms will be rather of the excitable than the apathetic 
kind. 

The physical condition will not be materially different, 
no matter what the cause of the shock or the nature of the 
early symptoms. If it is serious the torpid state will gradually 
deepen into coma, and the excitement as progressively subside 
into entire insensibility. The bodily heat may steadily become 
less, the breathing more superficial, the pulse weaker and more 
rapid, until death closes the scene. Sometimes this will be an 
unexpected end, the injury or nervous impression seeming totally 
inadequate to produce it. As lias already been affirmed, the result 
often depends more upon the physical condition of the patient, and 
the bodily ability to resist or sustain the deadly depressing 
influence, than upon the nature or extent of the injury itself. 



232 ORAL PATHOLOGY AND PRACTICE. 

CHAPTER LXV. 
TREATMENT OF SHOCK. 

The treatment of shock consists in the institution of measures 
to bring about a reaction. But these must be cautiously approached 
if the depression is very profound, or if it arises from or is accom- 
panied by any great loss of blood. There is danger that the 
reaction may be too great and exhaustive, or that recovery from 
the syncope or coma may be followed by a fatal return of the 
hemorrhage. Hence, in case of accident the precise condition 
should be determined before any extreme measures are attempted. ' 

Sometimes great difficulties are encountered in using 
the usual remedies. This is especially true in that common form 
of nervous shock called syncope, or fainting. Consciousness 
being lost, perhaps the patient cannot be made to swallow, and if 
fluids are forced into the mouth they will not be taken clown the 
esophagus, but may go into the trachea and cause suffocation. If 
the shock is so profound that the circulation is arrested, there will 
be little use in attempting hypodermic medication; and if the 
breathing is suspended, inhalations of volatile stimulants will be 
impossible. There will, of course, be cerebral anemia, and this 
should be at once combated by laying the patient in a recumbent 
position, with the head as low as the rest of the body, or even 
lower. All obstruction to a free circulation, like clothing that is 
too tight or a violently flexed position of any limb, should be 
remedied. The lower extremities may be raised, and pressure 
used to press the blood out of them toward the head. If there is 
blueness of the lips, it may indicate that the head is too low, or 
that there is some obstruction about the neck. 

As soon as possible, warm stimulating drinks should be given, 
such as dilute whiskey or brandy. Volatile stimulants may be 
applied to the nostrils, such as ammonia, nitrite of arriyl, etc., but 
care should be observed to avoid their being so unduly strong, or 
so persistently applied, as to cause suffocation. If the body is 
cold, external heat should be applied by wrapping the patient in 
hot blankets, or by laying bottles filled with water, not too hot, in 
the axilla; and about the body. Chafing the extremities should not 
be resorted to until consciousness has returned, lest it draw away 
the blood from the head, where it is most wanted. 



TREATMENT OF SHOCK. 233 

Artificial respiration should be used if the breathing is sus- 
pended and is not readily resumed. This may be continued as long 
as is necessary, but it should not be violent. Every precaution 
should be taken to avoid the deepening of the shock. It is need- 
less to say that in the unconsciousness resulting from drowning, 
the violent rolling of the body upon a barrel or other .object is the 
surest way to extinguish whatever of vitality may remain. 

If the stomach will not retain remedies, or if the patient can- 
not swallow, stimulating drinks may be administered as enemas, 
and alcoholic dilutions, or strong coffee, with carbonate of am- 
monia, etc., will be almost as useful as when given by the mouth. 

Hypodermic medication is very useful when the circulation has 
been maintained or restored. The activity of the heart may be 
stimulated by strychnin and digitalis. The respiration may be 
strengthened by atropin. These remedies should be given in large 
doses. Park recommends that in one hypodermic injection there 
should be given one c.c. of tincture of digitalis, with one-twentieth 
of a grain of strychnin and one-hundredth of a grain of nitro- 
glycerin. This to be repeated as often as necessary, or digitalis 
alone may be administered at frequent intervals. 

In case the shock takes the form of extreme nervous excitement, 
anodynes should be given. Opium, in the form of morphin sul- 
phate, is the most effective, and one-eighth to one-quarter of a 
grain may be administered hypodermically. The patient should be 
kepi as quiel as possible until reaction is complete. 

When the shock is due to great loss of blood, as from tooth 
extraction, a saline solution, consisting of sterilized water iooo 
parts, ammonium carbonate i part, and common salt 6 parts, may 
be sl< '\\ [) injected, the nearer to the place i if injury the better. 

The hypodermic syringe should always be kept in 
order, and be thoroughly sterilized before being used. The 
proper remedies may he obtained in tablet form, ready prepared 
for making solutions. The operator, before using the hypodermic 
solution, should see thai no .air is in the barrel, whence it may be 
driven into the circulation. This may 1><' determined by holding 
the point of the syringe up alter filling, ami expelling the air by 
means i »f the pisfc in. 

Of course, every operation is inhibited during the 
existence of shock. It matters nol what form it may take, 
whether thai of increasing lethargy or growing excitement, the 



234 ORAL PATHOLOGY AND PRACTICE. 

attention must at once be given to securing recovery. If indica- 
tions of hysteria are observable, that may be one of the symptoms 
of excitable shock, and the patient should be given an anodyne 
and placed in a recumbent position in a quiet place, the operation, 
if it be dental, not to be resumed until another day. 

No one suffering 1 from any form of shock, the result of an oral 
operation, should be allowed for a moment to remain in the operat- 
ing chair, as the recumbent position is the first essential. This 
does not seem to be properly appreciated by dentists. The extrac- 
tion of teeth, especially when an anesthetic is administered, can be 
much better accomplished when the patient is lying down. A 
couch, specially adapted to the purpose, should be provided by 
those who give anesthetics for the extraction of teeth. The danger 
from administration is very materially lessened, while convenience 
in operating is proportionately increased. The couch should be 
about the height of a common table, and only wide enough easily 
to hold the patient. Standing on either side for upper teeth, and 
at the head in extracting lower ones, the operator has much 
better command of the situation and is less liable to fracture tooth 
or alveolus, while the chances of dropping a fragment into the 
trachea, or of choking the patient with blood, are very materially 
lessened. Recovery from anesthesia, and from the shock conse- 
quent upon the operation, are much more prompt and satisfactory. 
No general surgeon would for a moment even consider the ques- 
tion of operating in any case with the patient sitting up. Dentists 
should change their methods, and — at least in operations involving 
the administration of anesthetics and the extraction of a number 
of teeth — adopt a position that is surgically more appropriate. 



INDEX. 



Acid fermentation, 10. 
Alcoholic fermentation, 9. 
Alg:e, the, 6. 

Alternate periods of growth, 58. 
Alveolar abscess, blind, 93. 
definition, 92. 
external treatment, 101. 
incipient, 93. 
infection not necessarily at foraminal 

opening, 94. 
secondary pockets and other complica- 
tions, 96. 
symptoms, 97. 
Alveolus, caries of, differs from that of 

bone, 154. * 
Arsenous ulceration, 47. 
Articulations, classification of, 225. 
Articulo-cartilage, 225. 
Anemia, 21. 
Aneurisms, 214. 

Animal and vegetable kingdoms, 4. 
Ankylosis, 216. 
Antiseptics, 14. 

Miller's table of, 16. 
Antiseptic mouth-washes, 79. 
Antrum a resonant chamber, 123. 
alveolar 'abscess discharging into, 127. 
catarrhal conditions, 126. 

of, 130. 
dilatation of walls, 129. 
drainage of, 131. 
foreign substance in, 128. 
iniundibulum opening into, 133. 

of walls, 131. 

opening of, 131. 
may not close, 134. 

■ •f tei th seldom penetrate, 127. 
septa dividing, 133. 
symptoms of degeneration in, 129. 
ti hi and plug in, 132. 
Aphthous stomatitis, 48. 

I'.ac u .1.1, the, 3. 

Bacteria, classification of, 4. 

self-limiting, i". 
Bad fi edtng, 60, 
Bandaging, 37. 
Birth-rate, 56. 
Bistoury in gum-lam in 



Black, G. V., experiments of, 77. 
I '.'caching teeth, chlorin in, 177. 
Hone, caries of, 15L 

Garretson's experiments, 153. 
symptoms of, 152. 
treatment of, 153. 
living portions may take on inflamma- 
tory conditions, 149. 
nourishment of, 148. 

osteitis the initial point in degenerations 
of, 149. 
the result of an irritant, 150. 
structure of, 148. 
I'reaking down of tissue. 32. 
Building up of tissue, 30. 

Cachectic conditions, 27. 
Cancers, malignant tumors, 144. 
Canorum oris, 44. 
Care concerning infection, 18. 
Caries limited by cleanliness, 78. 

prophylactics for, 78. 

of bone, symptoms of, 152. 
treatment of, 153. 
Caude of stomatitis. 45, 
Cement urn a modification of bone, 75. 
Chlorin in bleaching teeth, 117. 
Cocain formulae, 170. 
Cohnheim's observations. 27. 
Crowding of the dental profession, 39. 
Cryptogams, 6. 
Cyst, definition of, 137. 
liration of, 138. 

cause no functional disturbance, 137. 

classification of, 13^. 

dentigerous, 140. 

dermoidal, [40. 

Death, mean aj • 

I liath-i ii 

per© nts ■ ol 
d mion, 
iiciiial caries, ancient and modern, 70. 

M iller's theory. 71. 

I dentinal papillae, pr< 

I I en tin a modification of bone, 75- 
caries of, analogi ius to necn • 

hypei 1 Ihelics in obtunding, 

165. 

235 



236 



Dentin, hypersensitive, cataphoric medication 
in obtunding, 168. 
coagulation of fibrillte in obtunding, 168. 
gentleness a factor in obtunding, 170. 
inefficiency of medicinal agents in obtund- 
ing, 167. 
influence of heat and cold upon, 167. 
irritation of fibrillar in obtunding, 166. 
prophylactic medication as sedative, 169. 
not normally sensitive, 80. 
sensitive when irritated, 81. 
caries a cause of, 164. 
denudations a cause of, 164. 
due to irritation, 163. 
empirical remedies for obtunding, 161. 
vitiated oral secretions a cause of, 164. 
zone of infected, T2. 
Dentistry, "painless," 161. 

its true mission, 161. 
Dentition and the death-rate, 54. 

retarded, 68. 
Deodorants, 16. 
Detergents, 17. 
Diagram of death-rate, 62. 

of mortality from digestive diseases, 63. 
Diarrheas, formulae, 66. 
Diet among the poor, 61. 
Direct nervous action, 22. 
Discoloration not usual with living pulps, 

176. 
Diseases of dentition confined to a few 

months, 61. 
Disinfectants, 16. 
Dislocations, 225. 
classification of, 226. 
diagnosis of, 226. 
how treated, 227. 
of inferior maxilla, 227. 

Electricity in paralysis, 121. 

Electrozone, 16. 

Enamel a modification of bone, 76. 

congenital marks and the enamel organ, 180. 

influence of exanthematous disease on, 
180. 

pitted and furrowed, 179. 
Environments. 2. 
Epulis, character of, 147. 

from pericementum, 147. 
Evacuation of pus, 38. 
Experiments in inoculation, 13. 
Extraction in necrosis, 158. 
recumbent position in, 234. 

Facial paralysis, traumatic and idiopathic, 

119. 
Fermentation, 7. 

Ferments, organic and inorganic, 7. 
Fibrillje, inhibiting their ability to convey 

impulses, 166. 



Fibro-cartilage, 225. 
Filling sterilized roots, 102. 
First intention, 30. 
Fissation, 8. 

Follicular stomatitis, 42. 
Food, gradation to age, 59. 
Foramina, drilling open the, 101. 
Foraminal apex not necessarily the point 
of infection, 94. 
opening not a single direct aperture, 

Foreign substances in antrum, 128. 
Fractures, classification of, 218. 

deformity of, 218. 

delayed union in, 222. 

diagnosis of, 220. 

general treatment of, 223. 

how produced, 218. 

non-union of, 222. 

of the maxillae, 223. 

of the nasal bones, 222. 

reduction of, 221. 

treatment of compound, 221. 
Frontal sinus, opening of, 135. 
Function, normal and disturbed, 1. 
Functional harmony, 122. 
Fungi, aerogenic, 7. 

cnromogenic, 7. 

distinguishing characteristics, 6. 

multiplication of, 9. 

office of, 3. 

pure cultures of, 11. 

pyogenic, 7. 

resistance to, 12. 

saprogenic, 11. 

saprophytic, 11. 

Garretson, experiments of, on bone, 153. 

Gemmation, 8. 

Germicides, 15. 

Glossitis, 53. 

Granulation, or second intention, 31. 

Green stain, 103. 

Growth of fungi, 8. 

Gum irritants, 40. 

lancing, 68. 
Gums, appearance of, in health, 65. 
Gutta-percha caps over teeth, 91. 
Haversian canals, analogues of, in teeth, 

88. 
Heat as a sterilizer, "14. 

Hemorrhage, arterial, venous, and capil- 
lary, 216. 
Hemorrhagic diathesis, 218. 
Homologous and heterologous tumors, 142. 
Hydrogen peroxid, 16. 

Hypercementosis the analogue of exostosis, 
174. 

true cementum, 175. 



237 



Hyperemia, 21. 

Hypersensitive dentin due to inflamma- 
tions, 82. 
Hypodermic medication, 233. 

Implantation, no revivification of tissues 
in, 184. 

now an accepted practice, 183. 

physiology of, 185. 
Incubation in primary syphilis, 188. 

in secondary syphilis, 190. 

in tertiary syphilis, 191. 
Induration, 29, 103. 
Infection, - 18. 

care concerning, 18. 
Infective inflammation, 20. 
Inflammation, 21. 

general remedies for, 36. 

of pulp, 80. 

predisposing and exciting causes of, 26. 

stages of, 24. 

symptoms of, 25. 
Inorganic matter, 5. 
Insalivation, 1. 
Interference, external, 2. 
Ischemia, 21. 

Lactic acid treatment, 41. 
Laxatives, food and mineral, 87. 
Leafy cryptogams, 6. 
Leucocytes in the blood, 27. 
Lichens, 6. 
Ligaments, 226. 

Lupus, tuberculous nature of, 145. 
Luxations of lower jaw, 227. 

Malnutrition, 2. 
Massage in facial paralysis, 122. 
of the Kunis, 41. 

Media for organisms, 8. 
Metchnikoff's theory, 13. 

Microbes, 3, 

Micro-organisms, 3. 

M iller's theory of Caril 

Mortality, average infant, 56. 
Mouth-washes, antiseptic, 79. 

Neckosis, acid treatment of, 159. 
analogous to gangrene, 155. 
aa a sequela, 156. 
definition of, 3). 
diagnostic si^ns of, 157. 
drainage in, ivi. 
extraction in, 158. 
i" 11. r.-.l treatmi at of, 160. 
impacted teeth in. 156. 
indicative of debility, 155. 

operations for, 160. 

result of dental operations, 156. 
Nerve resection does not necessarily de- 
vitalize teeth, 89. 



Neuralgias, character of, 116. 

gouty diathesis in, 118. 

usually in afferent nerves, 115. 
Xoma, cancrum oris, 44. 
Non-union, 222. 
Nutritive changes in teeth, 124. 

Odontoblasts within the pulp, 171. 
Odontoma, 139. 
Oral pathology, 2. 

tissues, appearance of, in diseased con- 
ditions, 207. 
Organic matter, 4. 

Osteitis always present in pericemental in- 
flammation, 150. 

diagnosis of, 150. 

result of wedging, 151. 

Paralysis, reflex, 120. 
Pathogenic fungi, 11. 
Pathology, definition of, 2. 
Pericemental infection, 97. 

sterilization, 99. 
Pericementitis, calcium sulphide in, 91. 

hot water in, 91. 
Pericementum active in serumal forma- 
tions, ic6. 

a placental organ, 88. 

compound function of, 89. 

new growth of, 185. 
Phanerogams, 6. 
Pharyngitis, cause of, 49. 

in cleft palate, 50. 
Pharynx, the, \g. 
Physical diagnosis, 196. 
auscultation, 197. 
murmurs, 203. 
percussion, 197. 
Physiology, 1. 
Plantation of teeth, antiseptic, 182. 

Plastic exudate, 28. 

Plethora, 21. 

Poultices, 37. 

Pregnancy, sympathetic complications of, 
123. 

ii. '--1 1. 
Pulp, blood vessels of, mollified, 81. 
chamber opening, precautions in, 92. 
extravasation, 83. 

I ii in, sources of, 93. 
inflammation like other inflammations, 80. 
symptoms of, 85. 

treatment of, 86. 

irritation, symptoms of, 84. 

normally insensitive, 81, 
. 11 itivenesa due to irrital i< n 
tones analogous to osteo-dentin, 172. 

Pulpitis, comparative symptoms of, 90. 

Pulse, different kinds of, 199. 



2 3 8 



Pulse in health, 198. 
.rate at different ages, 198. 
where and how taken, 198. 
Pure cultures, 11. 
Pus, composition of, 17. 
different kinds of, 33. 
evacuation, 95. 
essential, 38. 
gatherings, abortive measures in, 98. 
Putrefactive fungi, 10. 

media, 13. 
Pyorrhea, chemical agents in treatment of, 
112. 
general treatment of, 114. 
in animals, 107. 
three forms recognized, no. 
without deposits, 114. 
Pyorrheal pockets, deflection of the teeth 
caused by, in. 
not always connected with oral cavity, 1 1 1 . 
Pyrozone, 16. 

Ranula, 139. 

" Raw ham" appearance, 189. 
Reflex nervous action, 23. 
Replantation, when called for, 1S1. 
Resection of maxillary nerves, 119. 
Resolution, 30. 
Respiration, artificial, 204. 
Sylvester's method, 204. 

in health and disease, 201. 

kinds of, 201. 

sounds heard in, 202. 

various rales, 203. 

Salivarv calculus, 104. 

Secondary dentin and pulp devitalization, 
173- 
as a protection, 172. 
common, 173. 
in animals, 172. 
not readily diagnosed, 174. 

formations due to special stimulus, 171. 
Segmentation, 8. 

Sensation in dentin due to irritation, 82. 
Sensitive apex of roots, 102. 
Septic and aseptic conditions, 14. 

conditions, general symptoms of, 98. 
Sequestrum, definition of, 35. 
Serumal calculus, 105. 
Shock, age and sex in, 208. 

anesthesia in preventing, 229. 

consequent on wounds, 208. 

definition of, 228. 

prohibits operations, 234. 

prophylaxis of, 230. 

susceptibility to, 229. 

treatment of, 232. 
Splints, 223. 
Spore-formation, 8. 



Sprains, 22S. 

Sterilization by absorption, 101. 

Stomatitis, cause of, 46. 

Successful operations, a test for, 163. 

Suppuration, 32. 

when to be encouraged, 99. 
Sympathetic dental disturbances, 123. 
Syphilis a constitutional, infectious dis- 
ease, 186. 

by inoculation, 186. 

care in diagnosing, 187. 

chancre rarely suppurates, 189. 
induration of, 188. 

chancres about the mouth, 194. 

chancroids, 192. 

condylomata, 192. 

glandular affections, 191. 

glossitis in, 195. 

gummata, 192. 

hereditary, 193. 

Hutchinsonian teeth, 193. 

infectious discharges, 191. 

mucous patches, 190. 

periods of incubation, 189. 

primary sore, or chancre, 187. 

readily yields to treatment, 186. 

secondary eruptions in the mouth, 194. 
symptoms, 189. 

"smoker's patches," 195. 

syphilides, 191. 

syphilitic children, 193. 

tertiary stage, 192. 

ulcerative lesions of the mouth, 194. 

Teeth are vital organs, 74. 

are modifications of bone, 73. 

composition of, 74. 

stained pink, blue, or green, 176. 

when "set on edge," 165. 
Thallogens, 6. 
Thrush, symptoms of, 43. 
Tissues, all, are organic, 77. 
"Toad's back" appearance, 195. 
Tongue as an index, 52. 

ulcers of, 54. 
Tongue, color of, in disease, 206. 

dry and moist, 206. 

"fur" coating of, 205. 

in diagnosis, 205. 

indications of danger by appearance of, 
207. 

natural appearance of, 205. 
Tonics, vegetable and mineral, 160. 
Tonsillitis, 51. 

Tooth abrasions, many forms of, 178. 
acid condition in, 178. 
prophylaxis of, 179. 
vitiated secretions in, 179. 

pulp normally insensitive, 162. 



239 



Torula, or yeast plant, 7. 
Transplantation, precautions in, 1S3. 
Trichloracetic acid, 41. 
Tumors, benign or malignant, 142. 

carcinomatous, 144. 

classification of, 142. 

comparison of, 146. 

diagnosis of, 143. 

epitheliomatous, 144. 

general treatment of, 143. 

homologous or heterologous, 142. 

sarcomatous, 144. 

structure of, 141. 

Ulcerative stomatitis, 43. 
Ulcers of the tongue, 54. 
Unhygienic conditions, 2. 
Uric acid diathesis, 108. 

Vaso-motor nerves, 23. 

Von Recklinghausen's theory, 29. 



Warts and corns, 141. 

White deposit, 103. 

Wounds, classification of, 209. 

closing of, 214. 

definition of, 20S. 

drainage of, 215. 

exuberant granulation of, 211. 

first, second, and third intention in heal- 
ing of, 210. 

hemorrhage in, '20S, 213. 
how controlled, 213. 

how distinguished, 208. 

loss of function after, 208. 

manner of healing, 210. 

septic conditions of, 212. 

shock after, 208. 



Zone of infected dentin, 
Zymogenic fungi, 7. 
Zymotic diseases, 12. 



72. 



JUL 8 18S8 






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